ncm 104 midterm exams- 1.docx

8/11/2019 NCM 104 MIDTERM EXAMS- 1.docx

1/21

1

NAME OF STUDENT: ________________________________ DATE: _____________ SCORE: ______ /"Whoever can be trusted with very little can also be trusted with much, and whoever is dishonest with very little

will also be dishonest with much." Luke 16:10 -(NIV)

1. What is the priority nursing diagnosis for a patient experiencing a migraine headache?a. Acute pain related to biologic and chemical factorsb. Anxiety related to change in or threat to health statusc. Hopelessness related to deteriorating physiological conditiond. Risk for Side effects related to medical therapy

2. You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which keyitems should be included in the teaching plan? (Choose all that apply).

a. Avoid foods that contain tyramine, such as alcohol and aged cheese.b. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.c. Abortive therapy is aimed at eliminating the pain during the aura.d. A potential side effect of medications is rebound headache.

e. Complementary therapies such as relaxation may be helpful.f. Continue taking estrogen as prescribed by your physician.

3. The patient with migraine headaches has a seizure. After the seizure, which action can you delegate tothe nursing assistant?a. Document the seizure.b. Perform neurologic checks.

c. Take the patients vital signs. d. Restrain the patient for protection.

4. You are preparing to admit a patient with a seizure disorder. Which of the following actions can youdelegate to LPN/LVN?a. Complete admission assessment.b. Set up oxygen and suction equipment.

c. Place a padded tongue blade at bedside.d. Pad the side rails before patient arrives.

5. A nursing student is teaching a patient and family about epilepsy prior to the patients discharge. Forwhich statement should you intervene?a. You should avoid consumption of all forms of alcohol. b. Wear you medical alert bracelet at all times. c. Protect your loved ones airway during a seizure. d. Its OK to take over -the- counter medications.

6. A patient with Parkinsons disease has a nursing diagnosis of Impaired Physi cal Mobility related toneuromuscular impairment. You observe a nursing assistant performing all of these actions. For whichaction must you intervene?a. The NA assists the patient to ambulate to the bathroom and back to bed.b. The NA reminds the patient not to look at his feet when he is walking.c. The NA performs the patients complete bath and oral care. d. The NA sets up the patients tray and encourages patient to feed himself.

7. The nurse is preparing to discharge a patient with chronic low back pain. Which statement by thepatient indicates that additional teaching is necessary?a. I will avoid exercise because the pain gets worse. b. I will use heat or ice to help control the pain. c. I will not wear high -heeled shoes at ho me or work. d. I will purchase a firm mattress to replace my old one.

8. A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenlystarted a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and

MI DTERM EXAM S
http://christianteens.about.com/od/versionsofthebible/p/NIV.htmhttp://christianteens.about.com/od/versionsofthebible/p/NIV.htmhttp://christianteens.about.com/od/versionsofthebible/p/NIV.htm


2/21

2

decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should youtake first?a. Administer the ordered acetaminophen(Tylenol).b. Check the Foley tubing for kinks or

obstruction.c. Adjust the temperature in the patients room. d. Notify the physician about the change in status

.9. Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to the

neurologic unit?a. A 28-year-old newly admitted patient with spinal cord injuryb. A 67-year-old patient with stroke 3 days ago and left-sided weaknessc. An 85-year-old dementia patient to be transferred to long-term care todayd. A 54-year-ol d patient with Parkinsons who needs assistance with bathing

10.A patient with a spinal cord injury at level C3-4 is being cared for in the ER. What is the priorityassessment?a. Determine the level at which the patient has intact sensation.b. Assess the level at which the patient has retained mobility.c. Check blood pressure and pulse for signs of spinal shock.d. Monitor respiratory effort and oxygen saturation level.

11.You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursingassistant when providing nursing acre for a patient with Spinal cord injury ?a. Assess patients respiratory status every 4 hours. b. Take patients vital signs and record every 4 hours. c. Monitor nutritional status including calorie counts.d. Have patient turn, cough, and deep breathe every 3 hours.

12.You are helping the patient with an SCI to establish a bladder-retraining program. What strategies maystimulate the patient to void? (Choose all that apply).a. Stroke the patients inner thigh. b. Pull on the patients pubic hair. c. Initiate intermittent straight catheterization.

d. Pour warm water over the perineum.e. Tap the bladder to stimulate detrusor muscle.

13.The patient with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device.When caring for this patient the nurse may delegate which action (s) to the LPN/LVN? (Choose all thatapply).a. Check the pat ients skin for pressure form device. b. Assess the patients neurologic status for changes. c. Observe the halo insertion sites for signs of infection.d. Clean the halo insertion sites with hydrogen peroxide.

14.You are preparing a nursing care plan for the patient with SCI including the nursing diagnosesImpaired Physical Mobility and Self- Care Deficit. The patient tells you, I dont know why were doing allthis. My lifes over. What additional nursing diagnosis takes priority based on this statement?

a. Risk for Injury related to altered mobilityb. Imbalanced Nutrition, Less Than BodyRequirements

c. Impaired Adjustment to Spinal Cord Injuryd. Poor Body Image related to immobilization

15.Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has beenon the neurologic unit for 1 week?a. A 34-year-old patient newly diagnosed with multiple sclerosis (MS)b. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS)c. A 56-year-old patient with Guillain-Barre syndrome (GBS) in respiratory distressd. A 25-year-old patient admitted with CA level spinal cord injury (SCI)


3/21

3

16.The patient with multiple sclerosis tells the nursing assistant that after physical therapy she is too tiredto take a bath. What is your priority nursing diagnosis at this time?a. Fatigue related to disease stateb. Activity Intolerance due to generalized weaknessc. Impaired Physical Mobility related to neuromuscular impairmentd. Self-care Deficit related to fatigue and neuromuscular weakness

17.The LPN, under your supervision, is providing nursing care for a patient with GBS. What observationwould you instruct the LPN to report immediately?a. Complaints of numbness and tinglingb. Facial weakness and difficulty speakingc. Rapid heart rate of 102 beats per minute

d. Shallow respirations and decreased breathsounds

18.The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has anelevated temperature (102.20 F), heart rate of 120/minute, rise in blood pressure (158/94), and wasincontinent off urine and stool. What is your best first action at this time?a. Administer an acetaminophen suppository.b. Notify the physician immediately.

c. Recheck vital signs in 1 hour.d. Reschedule patients physical therapy.

19.You are providing care for a pat ient with an acute hemorrhage stroke. The patients husband has beenreading 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 wifes brain. d. Your wife had gallbladder surgery just 6 months ago and this prevents the use of alteplase.

20.You are supervising a senior nursing student who is caring for a patient with a right hemisphere stroke.Which action by the student nurse requires that you intervene?a. The student instructs the patient to sit up straight, resulting in the patients puzzled expression. b. The student moves the patients tray to the right side of her over -bed tray.c. The student assists the patient with passive range-of-motion (ROM) exercises.d. The student combs the left side of the patients hair when the patient combs only the right side.

21.Which action (s) should you delegate to the experienced nursing assistant when caring for a patientwith a thrombotic stroke with residual left-sided weakness? (Choose all that apply).a. Assist patient to reposition every 2 hours.b. Reapply pneumatic compression boots.c. Remind patient to perform active ROM.d. Check extremities for redness and edema.

22.The patient who had a stroke needs to be fed. What instruction should you give to the nursingassistant who will feed the patient?a. Position the patient sitting up in bed before you feed her.

b. Check the patients gag and swallowing reflexes. c. Feed the patient quickly because there are three more waiting.d. Suction the patients secretions between bites of food.

23.You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patientcomplains of a severe headache with photophobia and has a temperature of 102.60 F orally. Whichcollaborative intervention must be accomplished first?a. Administer codeine 15 mg orally for the patients headache. b. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.c. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.d. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.


4/21

4

24. You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient withmeningococcal meningitis. Which action by the student requires that you intervene immediately?a. The student enters the room without putting on a mask and gown.b. The student instructs the family that visits are restricted to 10 minutes.c. The student gives the patient a warm blanket when he says he feels cold.d. The student checks the patients pupil response to light every 30 minutes.

25.A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with newonset generalized tonic- clonic seizures. Which nursing activities included in the patients care will be bestto delegate to an LPN/LVN whom you are supervising? (Choose all that apply).a. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures.b. Administer phenytoin (Dilantin) 200 mg PO daily.c. Teach patient about the need for good oral hygiene.d. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.

26.While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of thesenursing actions will you implement first if the patient has a seizure?a. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.

b. Administer lorazepam (Ativan) 1 mg IV.c. Turn the patient to the side and protect airway.d. Assess level of consciousness during and immediately after the seizure.

27.A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in theoutpatient clinic. Which information obtained during his chart review and assessment will be of greatestconcern?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 drivers license in the next month.

28.After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first?a. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retchingb. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teachingc. A 59-year- old with Parkinsons disease who will need a swallowing assessment before breakfastd. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain

29.All of these nursing activities are included in the care plan for a 78-year- old man with Parkinsonsdisease who has been referred to your home health agency. Which ones will you delegate to a nursingassistant (NA)? (Choose all that apply).a. Check for orthostatic changes in pulse and bloods pressure.b. Monitor for improvement in tremor after levodopa (L-dopa) is given.c. Remind the patient to allow adequate time for meals.d. Monitor for abnormal involuntary jerky movements of extremities.

e. Assist the patient with prescribed strengthening exercises.f. Adapt the patients preferred activities to his level of function.

30.As the manager in a long-term-care (LTC) facility, you are in charge of developing a standard plan ofcare for residents with Alzheimers disease. Which of these nursing tasks is best to delegate to the LPNteam leaders working in the facility?a. Check for improvement in resident memory after medication therapy is initiated.b. Use the Mini-Mental State Examination to assess residents every 6 months.c. Assist residents to toilet every 2 hours to decrease risk for urinary intolerance.d. Develop individualized activity plans after consulting with residents and family.

31.A patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of


5/21

5

Alzheimers disease. Her husband tells you that he rarely gets a good nights sl eep because he needs to besure she does not wander during the night. He insists on checking each of the medications you give her tobe sure they are the same as the ones she takes at home. Based on this information, which nursingdiagnosis is most appropriate for this patient?a. Decreased Cardiac Output related to poor myocardial contractilityb. Caregiver Role Strain related to continuous need for providing carec. Ineffective Therapeutic Regimen Management related to poor patient memoryd. Risk for Falls related to patient wandering behavior during the night

32.You are caring for a patient with a recurrent glioblastoma who is receiving dexamethasone (Decadron)4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessmentinformation concerns you the most?a. The patient does not recognize familymembers.b. The blood glucose level is 234 mg/dL.

c. The patient complains of a continuedheadache.d. The daily weight has increased 1 kg.

33.A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to thehospital ER . His wife tells you that he fell down the stairs about a month ago, but he didnt have a scratchafterward. She feels that he has become gradually less active and sleepier over the last 10 days or so.

Which of the following collaborative interventions will you implement first?a. Place on the hospital alcohol withdrawalprotocol.b. Transfer to radiology for a CT scan.

c. Insert a retention catheter to straightdrainage.d. Give phenytoin (Dilantin) 100 mg PO.

34.Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from themedical unit?a. A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the noseb. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured berryaneurysm.c. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibioticdose dued. A 65-year-old patient with a astrocytoma who has just returned to the unit after having a craniotomy35. Essential feature of glaucoma is:

a. Optic neuropathyb. Raised intraocular pressure

c. Reduced visiond. Painful eye

36. Which of these is not a feature of ocular hypertension?a. Elevated intraocular pressureb. Closed angle

c. Normal visual fieldsd. Normal optic discs

37. Risk factors for glaucoma include:a. Cardiovascular diseasesb. Family history of glaucoma

c. Hypothyroidismd. All of the above

38. Which of these is not a likely cause of painful red eye in a patient?

a. Open angle glaucoma

b. Closed angle glaucoma

c. Conjunctivitis

d. Herpes simplex39. 40.

1. ANSWER A The priority for interdisciplinary care for the patient experiencing a migraine headache

is pain management. All of the other nursing diagnoses are accurate, but none of them is as urgent

as the issue of pain, which is often incapacitating. Focus: Prioritization

2. ANSWERS A, B, C, D & E Medications such as estrogen supplements may actually trigger a


6/21

6

migraine headache attack. All of the other statements are accurate. Focus: Prioritization

3. ANSWER C Taking vital signs is within the education and scope of practice for a nursingassistant. The nurse should perform neurologic checks and document the seizure. Patients with

seizures should not be restrained; however, the nurse may guide the patients movements as

necessary. Focus: Delegation/supervision

4. ANSWER B The LPN/LVN can set up the equipment for oxygen and suctioning. The RN should

perform the complete initial assessment. Padded side rails are controversial in terms of whetherthey actually provide safety and ay embarrass the patient and family. Tongue blades should not be

at the bedside and should never be inserted into the patients mouth after a seizure begins. Focus:

Delegation/supervision.

5. ANSWER D A patient with a seizure disorder should not take over-the-counter medications

without consulting with the physician first. The other three statements are appropriate teachingpoints for patients with seizures disorders and their families. Focus: Delegation/supervision

6. ANSWER C The nursing assistant should assist the patient with morning care as needed, but

the goal is to keep this patient as independent and mobile as possible. Assisting the patient to

ambulate, reminding the patient not to look at his feet (to prevent falls), and encouraging the

patient to feed himself are all appropriate to goal of maintaining independence. Focus:Delegation/supervision

7. ANSWER A Exercises are used to strengthen the back, relieve pressure on compressed nerves

and protect the back from re-injury. Ice, heat, and firm mattresses are appropriate interventionsfor back pain. People with chronic back pain should avoid wearing high-heeled shoes at al times.

Focus: Prioritization

8. ANSWER B These signs and symptoms are characteristic of autonomic dysreflexia, a

neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause

of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for

poor catheter drainage, bladder distention, or fecal impaction is the first action that should betaken. Adjusting the room temperature may be helpful, since too cool a

temperature in the room may contribute to the problem. Tylenol will not decrease the autonomic

dysreflexia that is causing the patients headache. Notification of the physician may be necessary ifnursing actions do not resolve symptoms. Focus: Prioritization

9. ANSWER B The new graduate RN who is oriented to the unit should be assigned stable, non-

complex patients, such as the patient with stroke. The patient with Parkinsons disease needsassistance with bathing, which is best delegated to the nursing assistant. The patient being

transferred to the nursing home and the newly admitted SCI should be assigned to experienced

nurses. Focus: Assignment


7/21

7

10. ANSWER D The first priority for the patient with an SCI is assessing respiratory patterns and

ensuring an adequate airway. The patient with a high cervical injury is at risk for respiratory

compromise because the spinal nerves (C3 5) innervate the phrenic nerve, which controls thediaphragm. The other assessments are also necessary, but not as high priority. Focus:

Prioritization

11. ANSWER B The nursing assistants training and education include taking and recording

patients vital signs. The nursing assistant may assist with turning and repositioning the patient

and may remind the patient to cough and deep breathe but does not teach the patient how toperform these actions. Assessing and monitoring patients require additional education and are

appropriate to the scope of practice for professional nurses. Focus: Delegation/supervision

12. ANSWERS A, B, D & E- All of the strategies, except straight catheterization, may stimulate

voiding in patients with SCI. Intermittent bladder catheterization can be used to empty the

patients bladder, but it will not stimulate voiding. Focus: Prio ritization

13. ANSWERS A, C & D Checking and observing for signs of pressure or infection are within the

scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo

insertion sites with hydrogen peroxide. Neurologic examination requires additional education and

skill appropriate to the professional RN. Focus: Delegation/supervision

14. ANSWER C The patients statement indicates impairment of adjustment to the limitations of

the injury and indicates the need for additional counseling, teaching, and support. The other three

nursing diagnoses may be appropriate to the patient with SCI, but they are not related to the

patients statement. Focus: Prioritization

15. ANSWER B The traveling is relatively new to neurologic nursing and should be assignedpatients whose conditions are stable and not complex. The newly diagnosed patient will need to be

transferred to the ICU. The patient with C4 SCI is at risk for respiratory arrest. All three of these

patients should be assigned to nurses experienced in neurologic nursing care. Focus: Assignment

16. ANSWER D At this time, based on the patients statement, the priority is Self -Care Deficitrelated to fatigue after physical therapy. The other three nursing diagnoses are appropriate to a

patient with MS, but they are not related to the patients statement. Focus: Prioritization

17. ANSWER D The priority interventions for the patient with GBS are aimed at maintaining

adequate respiratory function. These patients are risk for respiratory failure, which is urgent. The

other findings are important and should be reported to the nurse, but they are not life-threatening.

Focus: Prioritization, delegation/supervision

18. ANSWER B The changes that the nursing assistant is reporting are characteristics of

myasthenia crisis, which often follows some type of infection. The patient is at risk for inadequate

respiratory function. In addition to notifying the physician, the nurse should carefully monitor the


8/21


9/21

9

Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes

initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient

started to seize. Documentation of the seizure, patient teaching, and planning of care are complexactivities that require RN level education and scope of practice. Focus: Delegation

26. ANSWER C The priority action during a generalized tonic-clonic seizure is to protect theairway. Administration of lorazepam should be the next action, since it will act rapidly to control

the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during

tonic-clonic seizures is caused by apnea. Checking the level of consciousness is not appropriateduring the seizure, because generalized tonic-clonic seizures are associated with

a loss of consciousness. Focus: Prioritization

27. ANSWER B Leukopenia is a serious adverse effect of phenytoin and would require

discontinuation of the medication. The other data indicate a need for further assessment and/or

patient teaching, but will not require a change in medical treatment for the seizures. Focus:Prioritization

28. ANSWER D Urinary tract infections are a frequent complication in patient with multiple

sclerosis because of the effect on bladder function. The elevated temperature and decreased breath

sounds suggest that this patient may have pyelonephritis. The physician should be notified

immediately so that antibiotic therapy can be started quickly. The other patients should beassessed soon, but do not have needs as urgent and this patient. Focus: Prioritization

29. ANSWERS A, C and E NA education and scope of practice includes taking pulse and blood

pressure measurements. In addition, NAs can reinforce previous teaching or skills taught by the RNor other disciplines, such as speech or physical therapists. Evaluation of patient response to

medication and development and individualizing the plan of care require RN-level education andscope of practice. Focus: Delegation

30. ANSWER A LPN education and team leader responsibilities include checking for the

therapeutic and adverse effects of medications. Changes in the residents memor y would be

communicated to the RN supervisor, who is responsible for overseeing the plan of care for eachresident. Assessment for changes on the Mini-Mental State Examination and developing the plan of

care are RN responsibilities. Assisting residents with personal care and hygiene would be delegated

to nursing assistants working the LTC facility. Focus: Delegation

31. ANSWER B The husbands statement about lack of sleep and anxiety over whether the

patient is receiving the correct medications are behaviors that support this diagnosis. There is no

evidence that the patients cardiac output is decreased. The husbands statements about how hemonitors the patient and his concern with medication administration indicate that the Risk for

Ineffective Therapeutic Regimen Management and falls are not priorities at this time.

Focus: Prioritization


10/21

10

32. ANSWER A The inability to recognize a family member is a new neurologic deficit for this

patient, and indicates a possible increase in intracranial pressure (ICP). This change should be

ommunicated to the physician immediately so that treatment can be initiated. The continuedheadache also indicates that the ICP may be elevated, but it is not a new problem. The glucose

elevation and weight gain are common adverse effects of dexamethasone that may

require treatment, but they are not emergencies. Focus: Prioritization

33. ANSWER B The patients history and assessment data indicate that he may have a chronic

subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the patient to surgeryto have the hematoma evacuated. The other interventions also should be implemented as soon as

possible, but the initial nursing activities should be directed toward treatment of any intracranial

lesion. Focus: Prioritization

34. ANSWER C This patient is the most stable of the patients listed. An RN from the medical unit

would be familiar with administration of IV antibiotics. The other patients require assessments andcare from RNs more experienced in caring for patients with neurologic diagnoses. Focus:

Assignment.35. a. Optic neuropathy 36. b. Closed angle 37. d. All of the above 38. b. Closed angle glaucoma

. Kelly Smith complains that her headaches areoccurring more frequently despite medications.Patients with a history of headaches should be

taught to avoid?

Chocolate

The nurse is caring for a male clientdiagnosed with a cerebral aneurysm whoreports a severe headache. Which action

should the nurse perform?

Call the physician immediately.


11/21

11

The client is seen in the clinic for treatment ofmigraine headaches. The drug Imitrex

(sumatriptan succinate) is prescribed for the client.Which of the following in the client s history

should be reported to the doctor?

Prinzmetals angina

The patient with migraine headaches has aseizure. After the seizure, which action can

you delegate to the nursing assistant?Take the patients vital signs.

The nurse answers a call bell and finds afrightened mother whose child, the patient, is

having a seizure. Which of these actionsshould the nurse take?

The nurse should clear the area and position the client safely

The client is experiencing seizure due to chemical imbalances. The followingare causes of seizure because of chemical imbalances EXCEPT: Alkalosis

The nurse is preparing a diet plan for a patient experiencing seizures. Whatplan of diet should the nurse prepare?

a diet high in fat and very low in carbohydrates and protein which can producedKetosis

In giving health teachngs to a patient experiencing seizures,the diet plan thatshould be avoided includes: Avoid excess sugar and caffeine

A patient is suddenly having seizure. As a nurse, an initial nursingintervention should include: Place the patient on side during a seizure

Assessment of Generalized tonic-clonic (grand mal) seizure includes all of thefollowing EXCEPT: Loss of contact with environment for 5 to 30 seconds.

The following are complicati ons related to seizure EXCEPT: Hypertension

A patient is admitted to the hospital for epeliptic seizure. Medications includewhich of the following: Anticonvulsants

A child is admitted to the hospital with an uncontrolled seizure disorder. Theadmitting physician writes orders for actions to be taken in the event of a

seizure. Which of the following actions would NOT be included?Restrain the patient's limbs

1. Which of the following best describes hydrocephalous? Abnormal accumulation of CSF in the ventricles

1. Which is not a symptom of acquired hydrocephalous? Delirium

1. All of the following are causes of acquired hydrocephalous except? Infection


12/21

12

hat procedure that involves the placement of a ventricular into the cerebralventricles to drain the excess fluid into the other body cavities? VP shunt

ra-axial tumors originate from the glial cells and arise from within the followingexcept? Meninges

1. It is common in patients with intracranial tumors and may be the firstmanifestation. It is also known as Choked Disc? Papilledema

Patient Magangana was diagnosed with brain tumor. She was scheduled forcraniotomy. In preventing development of cerebral edema after s urgery, the

nurse should expect the use of what medication?Steroids

ll but one is the best nursing responsibility of Nurse Magangana to take actionregarding monitoring for an increase ICP Assess neurologic status and vital signs frequently

Patient MD had a head trauma. She experience loss of consciousness for 5minutes and retrograde amnesia. There was no break in her skull or dura andno visible damage as seen in MRI. Nurse GGV knows that this type of trauma

is________

Concussions

__________ is the most severe fo rm of head injury because there is no focallesion to remove. Diffuse Axonal injury

1. The medical management of severely head-injured patients focuses onsupporting all organ system while recovery from the injury takes place. This

involves ___________All of the above

patient has loss of consciousness lasting 6 to 24 hours and has a short-termdisability. What type of diffuse axonal injury does the patient manifest? Mild axonal injury

linical manifestations of arteriovenous malformation include all the followingexcept: Focal neurologic lesions

. A patient is admitted with essential arteriovenous malformation. The nurseknows that most AVM are caused by an abnormality in embryonal

development that leads to:Tangle arteries and veins in the brain that lacks in capillary bed.

The nurse advises Mr. Nathan to bed rest with sedation. This advice is basedon the knowledge that rest and sedation

Prevent agitation and stress

oppler Ultrasonography of cerebrovascular system is used for arteriovenousmalformation that indicates: Turbulent blood flow

1. All of the following are cause by cerebral aneurysm except: Alcoholism

This is the most common type of cerebral aneurysm Saccular or berry aneurysm

Cerebral aneurysm most commonly occur at the bifurcations of the largearteries at the base of the brain, what is the specific location?

Cerebral arterial circle


13/21

13

1. A female client with a suspected brain tumor is cheduled for computedtomography (CT). what should the nurse do when preparing the client for this

test?

Determine whether the client is allergic to iodine, contrast dyes,or shellfish

The nurse is caring for a child with spina bifida which of the following factorsdetermines the extent of sensory and motor function loss in the lower limbs of

the child?Degree of spinal cord abnormality

1. Which assessment findings suggest hydrocephalus? Rapid increase in head size and irritabilit y

1. Which technique is more important for diagnosing hydrocephalus? Measurement of head circumference

All of the following are common etiology of spina bifida None of the above

1. Where is the usual location of meningocele? Posterior vertebral arches

1. Which one of the following phrases most accurately describesmyelomeningocele? Herniation of a portion of the spinal cord and meninges into a cyst.

A female patient is diagnosed with a CVA in the left hemisphere. The nurseexplains to the patient that her cerebral accidents (stroke) occurred in the left

hemisphere of her brain; therefore, she will have paresis (weakness) onThe right side of the body.

male patient recovering from a CVA is receiving oxygen therapy. The actionthe nurse should take before starting oxygen therapy is to? Keep the patients head slightly elevated and clear his mouth of secretions

1. The most common motor dysfunction of a stroke is: Hemiplegia

he degree of neurologic damage that occurs with the ischemic stroke dependson the: Combination of the above factors.

patient suffered a spinal cord injury in a swimming accident that resulted inquadriplegia. The nurse recognizes that the one major early problem for a

quadriplegia will be:Learning to use mechanical aids

The rehabilitation nurse is admitting a client following spinal cord injury. Thenurse concludes that the client has developed Brown-Sequared syndrome

after noting which of the following in the client?Ipsilateral proprioception loss below lesion

client who is recovering from a spinal cord injury complains of blurred visionand a severe headache. His blood pressure is 210/140. The most appropriateinitial action for the nurse to take is:

Check for bladder distention

hen the nurse asks a male patient with parkinsons disease to undress, thenurse observes that the patients upper arm tremors disappear as he

unbuttons his shirt. Which of the following statement would be the best toguide the nurse when analyzing her observation?

This type of tremor usually disappears with purposeful and voluntarymovements.

client with Parkinsons disease is receiving combination therapy with Levodopa(L-dopa) and Carbidopa (Sinemet). Which of the following manifestations

indicate to the nurse that an adverse drug reaction is occurring?Depression


14/21

14

nurse is teaching a family of a client with Parkinsons disease. Which of thefollowing statements by the family reflects a need for more education? We can buy lots of soups for dad.

he nurse is admitting a male patient with Parkinsons disease to the hospitalrecords that the patient has a shuffling and propulsive gait. If the nurse is

using the term propulsive gait correctly, she has observed that the patientswalk is characterized by:

slumping forward while walking

igns and symptoms seen in Parkinsons Disease result from the fact that thepatients body suffer from a: depletion of dopamine

hich of the following nursing goals is most realistic and appropriate in caringfor a patient with Parkinsons disease? Cure the disease in three to five years

hen the nurse asks a male patient with Parkinsons disease to undress, thenurse observes that the patients upper arm tremors disappear as he

unbuttons his shirt. Which of the following statements would be best to guidethe nurse when analyzing his observation?

This type of tremors usually disappears with purposeful and voluntarymovements

1. This type of food should be avoided when taking Levodopa except: a. Apple

is is a diagnostic procedure in patients with spinal cord injury if a ligamentousinjury is suspected. a. MRI

These are possible cause of hemorrhagic stroke, except Venous Thrombosis

A nurse is caring for a patient diagnosed with hemorrhagic stroke; the nursewould be alert for this complication. Seizure

1. IN relation to ischemic stroke, penumbra region is referred to: An area of low cerebral blood flow

. ____________ an autoimmune disorder caused by the destruction ofacetylcholine receptors. Myasthenia Gravis

My as th en ic c r i s i s and c h o l i n e rg i c c r i s i s are the major complications ofmyasthenia gravis. Which of the following is essential nursing

knowledge when caring for a client in crisis?

a. Weakness and paralysis of the muscles forswallowing and breathing occur in either

crisis

3. A client is admitted to the medical-surgicalfloor with an exacerbation of myasthenia gravis.

Which intervention is important for the nurse toinclude in the plan of care for this client?

. Scheduling the client's care around periods of rest.

Karina, a client with my as th en ia g rav i s is to receive immunosuppressivetherapy. The nurse understands that this therapy is effective because it:

Decreases the production of auto antibodies that attack the acetylcholinereceptors

The nurse is caring for a client admitted with suspected myasthenia gravis.Which finding is usually associated with a diagnosis of myasthenia gravis? Progressive weakness that is worse at the days end


15/21

15

ll of the fallowing are clinical manifestation of Guillain Barre Syndrome except: Headache

1. It is not recommended for the treatment of GBS Corticosteroids

respiratory distress with Guillain Barre Syndrome, we monitor for the fallowingexcept Vital signs

1. The cell that produces myelin in the nerve Schwann cell

1. Cerebral Palsy can be diagnosed as early as _____________? 4 months

esult in the damage or defects in the brains corticospinal pathways in eitherone or both hemispheres? a) Pyradimal/ spastic

1. 1. common The type of cerebral palsy a) Spastic cerebral palsy

. In planning a diet for a client with cerebral palsy, what would be the mostappropriate High calorie diet

. Which of the following pathophysiologic processes are involved in Multiple Sclerosis ?

Developmental of demyelination of themyelin sheath, interfering with nerve

transmission

Which of the following symptom usually occurs early in multiple sclerosis? Diplopia

The client with multiple sclerosis is experiencing dysphagia. Which of thefollowing foods is the most important for the client? vanilla pudding

Which of following condition or activities mayexacerbate multiple sclerosis (MS)? pregnancy

Which of the following client would be mostlikely to develop multiple sclerosis (MS)? A 35 years old white female teacher

1. The patient is suffering from herniated nucleus pulposus. Which of thefollowing does not aggravate the pain? a. Bed rest

1. The patient is experiencing muscle spasm. All of the following but oneis not an appropriate intervention? a. Narcotics

1. A pre-op patient who underwent a laminectomy needs furtherinstruction if she states that; a. Im not allowed to drink for four days


16/21

16

1. A patient was admitted to the hospital. The physician diagnosed thecondition of the patient as herniated nucleus pulposus. The nurse

on duty knows that herniated nucleus pulposus is the;

a. Profusion of the central part of interverfebral disk with the spinalcanal casing compression of spinal nerve roots.

1. As a nurse, you know that herniated nucleus pulposus is dominant tomen due to the heavy lifting. It is common in the _______and less

common/rare in _______ vertebral _______.a. Lumbar; cervical; space

1. A patient came into the emergency complaining of an increasingthrobbing headache that she characterized as a persistent aching

and burning pain. The nurse knows that the patient is suffering froma temporal arteritis. All of these are associated factors of temporal

arteritis except?

Nausea and vomiting

1. Tension headache is the most common type of headache, as a nurseyou know that tension headaches can be treated with all of the

following except?a. Corticosteriods

1. A patient complains of experiencing deep-seated, throbbing pain anddescribes the pain as aching or bursting. The nurse knows that the

patient is suffering from headaches of brain tumor that causesattacks of pain lasting a few minutes to an hour or more. All the

following are associated factors except one;

a. Loss of vision

1. Mr X was diagnosed with seizure. The affected part of his brain is thefrontal lobe. Nurse A would expect the pt. to have: a. Tremors that begin in the hands with unimpaired LOC

1. Mrs Samantha has a history of seizure while gardening. The patientsuddenly losses consciousness and fell on the floor. Upon

assessment, the patient has minimal abrasions increase pulse rateand perspiring. As a nurse, you know that the patient has a;

a. Grand mal Seizure

1. The physician ordered an anticonvulsant drug for a patient with seizureone of the nursing consideration is; a. An anticonvulsant should not be given with narcotic analgesics

1. Nurse Anna is monitoring the vital signs of the patient with seizures/What are the important vital signs should nurse Anna take? a. CV status, temperature and Respiration

1. Andie has bacterial meningitis, which of the following drug is mostlikely to administer for early diagnosis. a. Vancomycin HCI with cephalosporins

1. People in class contact with meningococcal meningitis should betreated with antimicrobial prophylaxis. The medication should be

administered:a. Within 24 hrs.

1. A patient who diagnose of meningitis can manifest a frequently initialsymtoms that the patient will experience throughout the course of

illness. Which of the ff. experiencing?d. Headache and fever

1. Doctor Jonathan diagnosed Mr. Santiago to have intracranialhemorrhage between cranium and outside the dura.The doctor iscorrect if he interprets that Epidural Hemorrhage is frequently due

to:c.Rupture of middle meningeal artery

17.Nurse Sarra is aware that Nuerological signs ofIntracranial Hemorrhage includes:EXCEPT b.Increase in respiratory

18. This results from spontaneous rupture of asmall penetrating artery deep in the brain? d. Intracerebral Hemorrhage


17/21

17

19. Mr. Reyes experienced pain when he flexedand extend his thigh on his abdomen at right

angle. This situation is significantly positive towhat condition?

d. Kernig s Sign

20. Antifibrolytics are used in the management ofhaemorrhagic lesion to: b. prevent fibrin clot degeneration

1. After experiencing a transient ischemic attack, aclient is prescribed aspirin, 325 mg p.o. daily. Thenurse should teach the client that this medicationhas been prescribed to:

d. Reduce platelet agglutination

2. A 70 year old client with a diagnosis of leftsided CVA is admitted to the facility. To preventthe development of disuse osteoporosis, which ofthe following objectives is most appropriate?

c. Promoting weight bearing exercises

3. Which nursing diagnosis takes highest priorityfor a client with Parkinson s crisis? b. Ineffective airway clearance

4. A client with a spinal cord injury andsubsequent urine retention receives intermittentcatheterization every 4 hours. The averagecatheterized urine volume has been 550 ml. thenurse should plan to:

a. Increase the frequency of the catheterizations

5. A client undergoes cerebral angiography fornurse evaluation of neurologic deficits. Afterward,

the nurse checks frequently for signs andsymptoms of complications associated with this procedure which findings indicate spasm orocclusion of a cerebral vessel by a clot?

b. Hemiplegia, seizures, and decreased level ofconsciousness

6. The nurse formulates a nursing diagnosis of riskfor altered body temperature for a client whosuffers a CVA after surgery. When developingexpected outcomes, the nurse incorporateassessment of the client s temperature to detectabnormalities. The thermoregulatory centers arelocated in which part of the brain?

d. Hypothalamus

7. A client recovering from a CVA has right sidedhemiplegia and telegraphic speech and oftenseems frustrated and agitated especially whentrying to communicate. However the chartindicates that the clients auditory and readingcomprehension are intact. The nurse suspects thatthe clients has:

b. Non-fluent aphasia


18/21

18

8. A client with parkinson s disease visits the physician s office for a routine check -up. Thenurse notes that the client takes

benztropine(cogentin), 0.5 mg p.o. daily and askswhen the client takes the drug during each day.Which response medicates that the clientunderstands when to take benztropine?

d. I take the medication at bedtime

9. After a CVA, a 75 yr old client is admitted tothe facility. The client has left sided weakness andan absent gag reflex. He s incontinent and has atarry stool. His blood pressure is 90/50 mmHg,and his Hgb is 10g. Which of the following is a

priority for this client?

d. Elevating the head of the bed to 30 degrees

10. During recovery from CVA, a client is givennothing by mouth to help prevent aspiration. Todetermine when the client is ready for a liquid diet, the nurse assesses the clients swallowing abilityonce each shift. This assessment evaluates:

d. CN IX & X

11. The nurse is caring for a client withhemiparesis caused by a CVA. Which interventiontakes the highest priority?

b. Placing the client on the affected side

12. A client injures the spinal cord in a divingaccident. The nurse knows that the client will beunable to breathe spontaneously if the injury siteis above which vertebral level?

a. C4

13. A white female client is admitted to an acutecare facility with a diagnosis of CVA. Her historyreveals bronchial asthma, exogenous obesity andiron deficiency anemia. Which history findigs is arisk factor for CVA?

c. Obesity

14. When teaching a client about levodopacarbidopa (sinemet) therapy for Parkinson sdisease, the nurse should include whichinstruction?

d. be aware that your urine may appear darker thanusual

15. The physician prescribes several drugs for a

client with hemorrhagic stroke. Which drug ordershould the nurse question? a. Heparin sodium (heparin sodium injection)

16. A client who recently experienced a CVA tellsthe nurse that he has double vision. Which nursingintervention is the most appropriate?

b. Alternatively patch one eye every 2 hours

17. For a client who has had a CVA, whichnursing intervention can help prevent contracturesin the lower legs?

d. Attaching braces or splints to each foot and leg


19/21

19

18. If a client experienced a cerebrovascularaccident that damaged the hypothalamus, thenurse would anticipate that the client has problemswith:

a. Body temperature control

19. Vince William, age 65 years old, is admitted

to the hospital with a diagnosis of Parkinson sdisease. Joel s symptoms are caused by:

d. an imbalance in dopamine andacetylcholine

20. Which clinical feature of the disease shouldthe nurse expect to see during admissionassessment?

b. mask like face and shuffling gait

e physician told that baby Megamind needs to undergo surgery that will createan opening to allow CSF to drain through a shunt from ventricles of the brain

into cisterna magna. What is this surgical procedure?a. Ventriculocisternostomy

It is a diagnostic procedure wherein a light is shone through a body area ororgan. a. Transillumination

Patient megamind was diagnosed with non communicating or intraventricularhydrocephalus, as a nurse we know that this problem can cause a non-

communicating hydrocephalus.a. Arnold-Chiari Syndrome

larissia an 8y/o child that has been diagnosed to have brain tumor. The doctoradvised the parents of clarissa to get their child for treatment. You know as a

nurse that the best treatment for clarissa would be:a. Chemotherapy

6. In relation to the question in no.1. Clarissa s parents ask what is the action of the treatment. As

a nurse your answer would be:a. Its goal is to kill tumor cells with the aid of drugs.

7. Leren has breast cancer for 5 years, the cancerhas already metastasized through her bodyreaching the brain . What do you call this

condition?

b. Secondary brain tumor

10. Patient Tin is classified as grade 3 in SpetzlerMartin Grading for microsurgery. What does it

implies?a. She may or may not be amenable for a surgery

11. This is a type of stroke that is caused by bleeding into the subarachnoid space in the area between the brain and the skull which contain

CSF.

b. SAH

12. Mr. Q was diagnosed with AVM. What part ofthe brain is removed if he is required to have a

supra tentorial surgery?c. Above the tentorium

13. Mr. R, a 42 years old police officer wasdiagnosed of having AVM and was ready toundergo what appropriate type of surgery?

b. microsurgery


20/21

20

14. Baby Marco, a 7 months old is brought by hismother to the hospital because of noticeable

enlargement of the head. As a student nurse youknow that baby Marco is suffering from

hydrocephalus because as you further assess thesymptom it shows the ff. except:

d. Nuchal rigidity

15. In relation to question #6 after the diagnostic procedure is done, baby Marco have to undergo

surgery. Prior to surgery you do your nursingmanagement that include the ff. except:

d. Monitor for Signs and Symptoms or HCP andinfection

16. Mr. You was brought to the EmergencyDepartment by his wife due to the vehicular

accident. The patient undergone an immediateSkull x-ray that reveals Mr. You has Depressed

Skull Fracture. As a nurse, you are aware thecharacteristic of Depressed Skull Fracture is?

a. A break in a cranial bone or "crushed" portion of skull with

depression of the bone in toward the brain

17. Nurse Biwit is taking the history of his patientexperiencing head injury, he should know that the

most common symptom of concussion isa. Headache

18. Nurse Biwit has a patient who has a historyofhead injury, during health teaching, nurse Biwit

includes all of the following regarding the prevention of head injury except?

*c. Cap in construction

19. A 55 y/o male client was diagnosed withfusiform cerebral aneurysm that needs an urgentmedical treatment . What should be the first

nursing intervention?

* b. Monitor V/S

20. A relative of a client with cerebral aneurysmask the nurse what does it means. The nurse s

appropriate response would be:

*c. Is a dilation of the walls of the cerebral arterythat develops as a result of weakness in the arterial

wall.

You are about to administer 20 mg. of Capoxane to a patient with relapsing-remitting Multiple Sclerosis, what is the only route used in administering this

drug?a. Subcutaneous

Which of the following suggest why patients with Multiple Sclerosis developdepression?

a. Depression is a side effect of some drugs used to treat MSsuch as steroids and Interferon.

. What is the virus most often associated with Guillaine-Barre Syndrome? a. Campylobacter Jejuni

ecause Myasthenia Gravis may involve the muscle of respiration, what actionwill you do to prevent a patient from experiencing dyspnea and ineffective

cough and swallow mechanism?a. Encourage deep breathing and coughing.


21/21

his is an autoimmune disease that persists on muscular weakness and fatiguethat worsens with exercise and improves with rest? a. Myasthenia Gravis

. Brad Feet a 25 year old patient with Guillaine-Barre Syndrome is having arespiratory distress which of the following will you expect to see connected to

the patient?a. Mechanical Ventilator

1. Which of the following diagnoses is appropriate for a client with MultipleSclerosis? a. Impaired urinary elimination related to bladder dysfunction.

. Which of the following is a unique clinical manifestation of Guillaine-BarreSyndrome? a. Ascending weakness

ncm 104 midterm exams- 1.docx

Documents