Medications
A 73 year-old patient has been diagnosed with ischemic stroke following diagnostic studies. Which medication must be given within a 4.5 hour window of symptom onset to be effective in lysing a clot?
1. heparin
2. Xarelto
3. Plavix
4. Alteplase
4. Alteplase
Rationale: Options A, B, and C will not cause lysis of a clot. Altepase (tPA) is the only FDA-approved medication that will dissolve a clot. Altepase binds to fibrin and converts plasminogen to plasmin, which is responsible for clot breakdown.
What is the most common initial symptom that a nurse might expect a patient with MS to complain about?
1. diarrhea
2. headaches
3. skin infections
4. visual disturbances
4. visual disturbances
Rationale: Although the s/s of MS are varied and multiple, reflecting the location of the lesion or a combination of lesions. The primary symptoms most often reported are unilateral vision loss, typically preceded or accompanied by orbital pain that increases with eye movement (acute optic neuritis), fatigue, depression, weakness, limb numbness, difficulty in coordination, loss of balance, and pain.
A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling". Which is the most appropriate initial reaction by the nurse?
1. Try to calm the patient and make the environment soothing
2. assess for a full bladder
3. notify the healthcare provider
4. prepare the patient for diagnostic radiography
2. assess for a full bladder
Rationale: Autonomic dysreflecia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea.
The patient is rushed into the emergency department by a family member who states the patient is having a stroke. Which action does the nurse take first?
1. call for the provider to see the patient STAT
2 call radiology to have them clear the CAT scan table
3. Ask the family member when the patient was last seen to be normal
4. assess the patient for unilateral neurological deficits
4. assess the patient for unilateral neurological deficits
Rationale: The nurse first assesses the patient for the presence of stroke symptoms; this can be done by assessing for unilateral neurological deficits. If the nurse determines the presence of unilateral neurological deficits, then the nurse calls the provider to see the patient STAT, obtains a thorough history, and expedites a CAT scan
An adult patient with type 1 diabetes mellitus and Parkinson's disease lives alone. Which statement by the patient would prompt the nurse to advocate for a delay in discharge from the hospital?
1. "I will not be able to do the dressing changes for my pressure ulcer every three days by myself".
2. "My son visits me every day, but only stays for an hour or less each visit."
3. "I cannot give myself my own insulin because my hands shake too much."
4. "I need my walker to get around my house. My Son has picked up all of the rugs."
3. "I cannot give myself my own insulin because my hands shake too much."
Rationale:If the patient cannot self-administer insulin shots due to shaking hands from Parkinson’s, the patient is not safe to live alone. Discharge should be delayed until continuous nursing care is obtained, or the patient is able to cohabitate with someone who can provide around-the-clock care.
The incidence of ischemic strokes in patient with TIA’s and other risk factors is reduced with the administration of which medication?
1. Furosemide (Lasix)
2. Lovastatin (Mevacor)
3. Daily low-dose aspirin
4. Nimodipine (Nimotop)
3. Daily low-dose aspirin
Rationale: Aspirin is an anti-platelet aggregator and will aid in preventing the formation of clots.
A patient who has Guillain-Barre asks, “Will I ever get better?” Which response would be the most appropriate answer by the nurse?
1. “You’ll notice your strength will improve each day.”
2. “We are doing everything we can to provide the best care.”
3. “You seem concerned about getting better. What do you think?”
4. "Your chances for recovery are very good, but recovery is slow.”
3. "You seem concerned about getting better. What do you think?"
Rationale: Option 3 is the most therapeutic response of the 4 options.
A nurse in a long-term care facility is caring for a 78-year-old man with dementia. Which of the following are the main signs and symptoms of Alzheimer's dementia?
1. Impaired motor skills and lack of coordination
2. delusions and hallucinations
3. weight loss, fatigue, and hopelessness
4. poor judgment, memory deficit, and irritability
4. poor judgment, memory deficit, and irritability
Rationale: Dementia is a cognitive condition resulting from a disease or injury and is characterized by memory problems, impaired reasoning, and personality changes. Patients with dementia exhibit manifestations of poor judgment, memory, and irritability. Impaired motor skills and lack of coordination are seen in movement disorders, such as Parkinson’s disease. Delusions and hallucinations are more typical of a psychotic illness, such as schizophrenia. Weight loss, fatigue, and hopelessness are more typical of major depressive disorder.
An 82-year-old client with a history of hypertension becomes acutely confused and complains of a severe headache. The nurse is concerned the client is having a stroke. Which action should the nurse take first?
1. obtain a full set of vitals
2. perform a mini mental status exam
3. assess the client using the Glasgow Coma Scale
4. ask the client to smile, speak their name, and then hold out their arms
4. ask the client to smile, speak their name, and then hold out their arms
Rationale:
The fastest way to assess for a stroke is to use the “FAST” technique:
F= facial drooping and uneven smile;
A= arm weakness, inability to lift both arms;
S=speech difficulty, inability to repeat a simple sentence;
T=seek immediate care or intervention.
A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which action should the health care team take in order to promote adequate nutrition for this patient?
1. Provide a diet that is low in complex carbohydrates and high in protein.
2. Provide small, frequent meals throughout the day that are easy to chew and swallow
3. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.
4. Request placement of a feeding tube to prevent aspiration
2. Provide small, frequent meals throughout the day that are easy to chew and swallow
Rationale: Patients with PD are at risk for dysphagia and will tire easily when chewing.
A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication?
1. "I will stop taking this medicine if I notice any bruising."
2. "I will not eat spinach while I'm taking this medicine."
3. "It will be okay for me to eat anything, as long as it is low fat."
4. "I'll check my blood pressure frequently while taking this medication."
2. "I will not eat spinach while I'm taking this medicine."
Rationale: Warfarin is a vitamin K antagonist. Green leafy vegetables contain vitamin K, and will therefore interfere with the therapeutic effects of the drug.
The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided?
1. Reposition the patient every two hours
2. Position the patient with the head elevated 30 degrees
3. suction the airway every two hours per standing orders
4. provide continuous oxygen as ordered
3. suction the airway every two hours per standing order
Rationale: suctioning further increases ICP. Therefore, suctioning should be done to maintain a patent airway, but not as a matter of routine. The other choices help the patient maintain comfort and can help control or reduce ICP (or even prevent IICP).
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?
1. fluid is clear and tests negative for glucose
2. fluid is grossly bloody in appearance and has a pH of 6
3. fluid clumps together on the dressing and has a pH of 7
4. fluid separates in concentric rings and tests positive for glucose
4. fluid separates in concentric rings and tests positive for glucose
Rationale: CSP can be distinguished from other bodily fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid will also test positive for glucose.
A patient being cared for on the neurologic unit has a diagnosis of acute ischemic stroke. It has affected the left hemisphere of the patient’s brain. The nurse would expect to assess which deficit in this patient?
1. Left-sided hemiparesis
2. aphasia
3. left field visual deficit
4. lack of awareness deficit
2. aphasia
Rationale: Left hemispheric strokes often result in the following: paralysis/weakness of the right side of the body, right visual field deficit, aphasia (expressive, receptive, or global), altered intellectual ability, and slow, cautious behavior.
While assessing a patient with Parkinson disease, the nurse identifies bradykinesia when the patient exhibits which symptom?
1. muscle flaccidity
2. an intention tremor
3. paralysis of the limbs
4. slow, spontaneous movement
4. slow, spontaneous movement
Rationale: Bradykinesia is used to describe a slowness of initiation and execution of movement.
A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT?
1. Adenosine
2. Warfarin
3. Atropine
4. Norepinephrine
3. Atropine
Rationale: Atropine will quickly increase the heart rate and block the effects of the parasympathetic system on the body. Remember bradycardia occurs in neurogenic shock because the sympathetic nervous system (which increases the heart rate) loses its ability to stimulate nerves.
The nurse is reviewing the lab results several clients. finding should the nurse report to eh the health care provider first?
1. client who has a sodium of 140 mEq/L
2. client who reports nausea with a lithium level of 1.8 meQ/L
3. client with a heart rate of 62 bpm who has a dioxin level of 1.4 mg/mL
4. a pregnant woman whose fibrinogen level is 500 mg/dL
2. client who reports nauseas with a lithium level of 1.8 mEq/L
Rationale: This patient has lithium toxicity. Lithium has a narrow therapeutic range of 0.6 - 1.2 mEq/L.
The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?
1. "I will wash my face with cotton pads."
2. "I'll have to start chewing on my unaffected side."
3. "I should rinse my mouth if toothbrushing is painful."
4. "I'll try to eat my food either very warm or very cold."
4. "I'll try to eat my food either very warm or very cold."
Rationale: Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client needs to chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If brushing the teeth triggers pain, and oral rinse after meals may be helpful instead.
A nurse is creating a plan of care for a patient who is experiencing homonymous hemianopsia after a stroke. The nurse documents interventions that will promote a safe environment, knowing that in this disorder, the patient experiences which symptom?
1. has a visual loss in the same half of the visual field of each eye
2. has lost the ability to recognize familiar objects through the senses
3. is unable to carry out a skilled act such as dressing, in the absence of paralysis
4. has paralysis of the sympathetic nerves of the eye causing ocular manifestations
1. has a visual loss in the same half of the visual field of each eye
Rationale: Homonymous hemianopsia is a visual loss in the same half of the visual field of each eye, so the patient has only half of the normal vision. Option 3 is apraxia. Option 4 describes Horner’s syndrome.
The nurse is providing home care instructions to a patient with Parkinson's disease about measure to control a right-sided tremor. What instruction should the nurse give to the patient?
1. Sleep on the unaffected side
2. use the left hand only to perform tasks
3. use the right hand only to perform tasks
4. squeeze a rubber ball with the right hand
4. squeeze the rubber ball with the right hand
rationale: The patient with a tremor is instructed to use both hands to accomplish a task. The patient is also instructed to hold change in a pocket or to squeeze a rubber ball with the affected hand. The patient should sleep on the side that has the tremor to control it.
The nurse is caring for a patient with bacterial meningitis. The provider has prescribed mannitol to this patient. The patient’s mother asks why this medication has been prescribed. Which of the following responses by the nurse is most appropriate?
1. "Mannitol will help your child to increase urine output."
2. "Mannitol will kill the bacteria that is making your child sick."
3. "Mannitol will help to decrease the pressure in your child's head."
4. "Mannitol is contraindicated for your child. I will contact the provider for an alternative medication."
3. "Mannitol will help to decrease the pressure in your child's head."
Rationale: Mannitol is an osmotic diuretic that decreases intracranial pressure. Although it is a diuretic, it is not used to increase urine output. It is not an antibiotic medication and is not contraindicated in meningitis.
You're developing a plan of care of a patient with multiple sclerosis who presents with Uhthoff's Sign. What interventions will you include in the patient's plan of care? Select All That Apply.
1. Avoid Movements of the head and neck downward
2. Keep the room temperature cool
3. Encourage patient to use warm packs and heating pads for symptoms
4. Educate the patient on 3 ways to avoid overheating during exercise
2 and 4
Rationale: Uhthoff’s Sign is where when the patient experiences too much heat their symptoms increase and get worst. Therefore, it is important the patient stays cool and doesn’t overheat.
A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness?
1. giving client full control over care decisions and restricting visitors
2. providing positive feedback and encouraging active range of motion
3. providing information, giving positive feedback, and encouraging relaxation
4. providing IV administer sedatives, reducing distractions, and limiting visitors
3. providing information, giving positive feedback, and encouraging relaxation
Rationale: The client with GB experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's conditions, giving expert care and positive feedback ,and encouraging relaxation and distraction.
A client is hospitalized when they present to the ED with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits have resolved and the client is back to their pre symptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
1. Cerebral aneurysm
2. Transient Ischemic Attack
3. Left-sided stroke
4. Right-sided stroke
2. Transient Ischemic Attack
Rationale: A TIA is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her pre symptomatic state.
Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of this medication. Which finding indicates that the client is experiencing an adverse effect?
1. Pruritus
2. Tachycardia
3. Hypertension
4. Impaired voluntary movements
4. impaired voluntary movements
Rationale: Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages.