Thanks
A nurse is caring for a client post-lumbar puncture who reports a throbbing headache when sitting upright for meals. Which of the following are appropriate actions by the nurse? (Select all that apply)
A. Use the Glasgow Coma Scale when assessing the client
B. Assist client to eat meals while lying flat in bed
C. Administer an opioid medication
D. Encourage client to increase fluid intake
E. Place client in a "cannonball" position
B, C, D
A patient with head trauma is being monitored with an intraventricular catheter device (IVC). The patient's ICP has been staying around 20mmHg, but moments ago, it spiked up to 55mmHg. What complications related to the monitoring device itself would best explain this dramatic increase in ICP.
a. Infection at the catheter access site
b. Obstruction of the catheter
c. Hemorrhage
d. Misplacement of catheter
b. Obstruction of the catheter
Which patient below is at the most risk for a hemorrhagic stroke?
A. A 65-year-old male patient with carotid stenosis
B. A 89 year old female with atherosclerosis
C. An 88-year-old male with uncontrolled hypertension
D. A 55-year-old female with atrial flutter.
C. An 88-year-old male with uncontrolled hypertension
Which tests below can be ordered to help the physician diagnose Guillain-Barré Syndrome? Select all that apply:
A. Edrophonium Test
B. Sweat Test
C. Lumbar puncture
D. Electromyography
E. Nerve Conduction Studies
C. Lumbar puncture
E. Nerve Conduction Studies
A nursing student is reviewing a patient for risk factors that increase the likelihood of a stroke. Which of the following would the student be correct to identify? SATA
A. 20-year pack history
B. 65+
C. Family history of CABGs
D. Frequent runner
E. BMI 37
F. Poor PO intake
A. 20-year pack history
B. 65+
E. BMI 37
When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as:
a. flexion withdrawal.
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing.
c. decorticate posturing.
What is the most accurate device for measuring ICP?
a. Intraventricular
b. Intraparenchymal
c. Lumbar/subarachnoid
d. Subdural
a. Intraventricular
A patient with a TBI is at high risk for a secondary brain injury. What is the best nursing explanation of a secondary brain injury?
a. Result of a repeated assault incident
b. From a penetrating gunshot wound
c. Trauma inflicted by another person
d. Cerebral edema and ischemia
d. Cerebral edema and ischemia
A patient in the ER is admitted with the following complaints: inability to keep eyes open, extreme fatigue that is relieved with naps, and blurred double vision. These symptoms have progressed over several months, but have begun to interfere with the patient’s work and social life. Which of the following tests should you anticipate? SATA
A. CT brain
B. Blood draw
C. Tensilon test
D. Echo
E. KUB
F. X-ray
B. Blood draw
C. Tensilon test
Bonus: Which condition would be diagnosed with a positive Tensilon test?
A nurse is caring for a patient with an increased risk for stroke development. What signs and symptoms should the nurse teach the spouse are signs and symptoms of a stroke? SATA
A. PERRLA
B. Unable to ambulate without assistance
C. Even smile
D. Arm drift
E. Sudden changes in speech
F. Vomiting
B. Unable to ambulate without assistance
D. Arm drift
E. Sudden changes in speech
F. Vomiting
The physician orders intracranial pressure (ICP) readings every hour for a 23-yr-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action?
a. Document the ICP reading in the chart.
b. Determine if the patient has a headache.
c. Assess the patient's level of consciousness.
d. Position the patient with head elevated 60 degrees.
c. Assess the patient's level of consciousness.
A nurse is caring for a patient with an arteriovenous malformation (AVM). What symptom is the nurse most likely to observe in this patient?
a. Seizure
b. Headache
c. Intracranial pressure
d. Hemorrhage
d. Hemorrhage
A patient is admitted with uncontrolled atrial fibrillation. The patient’s medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for?
A. Ischemic thrombosis
B. Ischemic embolism
C. Hemorrhagic
D. Ischemic stenosis
B. Ischemic embolism
You're assessing your patient's pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as:
A. Hemianopia
B. Opticopsia
C. Apraxia
D. Ataxia
A. Hemianopia
A patient has experienced right side brain damage. You note the patient is experiencing neglect syndrome. What nursing intervention will you include in the patient’s plan of care?
A. Remind the patient to use and touch both sides of the body daily.
B. Offer the patient a soft mechanical diet with honey thick liquids.
C. Ask direct questions that require one word responses.
D. Offer the bedpan and bedside commode every 2 hours.
A. Remind the patient to use and touch both sides of the body daily.
Determine this patient's GCS:
A 6 year old male fell 6 feet from a tree. He is awake and has the ability to move all of his extremities. When you ask what happened he tells you that he sell and then begins to tell you about his pet dog.
15 - Perfect!
A patient has been diagnosed with Guillain-Barre syndrome and is experiencing ascending, symmetrical muscle weakness and paralysis. Which nursing intervention could best help prevent complications of immobility?
a. Assess strength of neck flexor muscles
b. Promote use of antiembolism stockings
c. Assist with plasmapheresis treatment
d. Administer IV immunoglobulin
b. Promote use of antiembolism stockings
In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered?
A. 6 hours after the onset of stroke symptoms
B. 3 hours before the onset of stroke symptoms
C. 3 hours after the onset of stroke symptoms
D. 12 hours before the onset of stroke symptoms
C. 3 hours after the onset of stroke symptoms
A 25 year-old presents to the ER with unexplained paralysis from the hips downward. The patient explains that a few days ago her feet were feeling weird and she had trouble walking and now she is unable to move her lower extremities. The patient reports suffering an illness about 2 weeks ago, but has no other health history. The physician suspects Guillain-Barré Syndrome and orders some diagnostic tests. Which finding below during your assessment requires immediate nursing action?
A. The patient reports a headache.
B. The patient has a weak cough.
C. The patient has absent reflexes in the lower extremities.
D. The patient reports paresthesia in the upper extremities.
B. The patient has a weak cough.
While providing self-care instructions to the client diagnosed with multiple sclerosis, which intervention will the nurse instruct the client to implement to decrease the occurrence of fatigue?
A. Soak in a hot tub to help relax muscles and decrease fatigue
B. Avoid exercises and activities that result in body overheating
C. Strive to maintain mobility by participating in daily aerobics
D. Avoid sleeping longer than 6 hours to prevent muscle fatigue
B. Avoid exercises and activities that result in body overheating
Determine this patient's GCS:
A 24 year old female overdosed on an unknown substance. She is staring off into space, babbling, when you apply painful stimulus she cries out in comprehensively but does not pull away.
9
Eye response to pain - 2
Incomprehensible sounds - 2
Moves to localized pain - 5
A 45-year-old man in the ICU is diagnosed with generalized myasthenia gravis. The physician is discussing treatment options with the patient. The nurse understands that which treatment option would likely be the most effective for this patient in the long term in terms of remission, overall survival, and clinical improvement?
a. Anticholinesterase
b. Plasmapheresis
c. IV immunoglobulin
d. Thymectomy
d. Thymectomy
You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. The patient scores a 40. According to the scale, the result is:
A. No stroke symptoms
B. Severe stroke symptoms
C. Mild stroke symptoms
D. Moderate stroke symptoms
B. Severe stroke symptoms
You are assessing a patient with signs and symptoms of a stoke. Assign the signs and symptoms to the correct sie of the brain damage.
A. Right-side hemiplegia
B. Disoriented
C. Difficulty with speech
D. Cannot
E. Code gray
F. Poor attention span
A. Left
B. Right
C. Left
D. Left
E. Right
F. Right
The client who is diagnosed with Parkinson disease (PD) is on multiple medications, including benztropine. When providing education to the client regarding the management of PD, which information should the nurse provide to address the anticholinergic side effects of the benztropine? Select all that apply.
A. “Chewing sugar free gum helps to moisten your mouth.”
B. “Increasing foods that are rich in fiber is important to decrease constipation.”
C. “Be sure to monitor your intake and output as urinary retention may occur due to your prescribed medication.”
D. “You should decrease your intake of fluids due to the risk for urinary retention.”
E. “Taking a walk everyday is a strategy to address constipation.”
A. “Chewing sugar free gum helps to moisten your mouth.”
B. “Increasing foods that are rich in fiber is important to decrease constipation.”
C. “Be sure to monitor your intake and output as urinary retention may occur due to your prescribed medication.”
E. “Taking a walk everyday is a strategy to address constipation.”