Neuro
Which nursing intervention would the nurse implement for a hospitalized client with multiple sclerosis who voices a concern about generalized weakness and fluctuating physical status?
A. Encourage bed rest for this client.
B. Space activities throughout the day.
C. Teach the limitations imposed by the disease.
D. Have one of the client’s relatives stay at the bedside.
Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Stress the client’s strengths, rather than limitations. Having one of the client’s relatives stay at the bedside is unnecessary. The nurse’s responsibility is to maintain client safety and meet client needs.
Damage to which cranial nerve may lead to decreased olfactory acuity?
A. Cranial nerve I
B. Cranial nerve X
C. Cranial nerve V
D. Cranial nerve VIII
Cranial nerve I, also known as the olfactory nerve, originates at the olfactory bulb and assists with the perception of smell. Damage to this nerve may cause a decrease in olfactory acuity. Cranial nerve X, also known as the vagus nerve, has both sensory and motor functions. Cranial nerve V, also known as the trigeminal nerve, has both sensory and motor functions. Cranial nerve VIII, also known as the vestibulocochlear nerve, assists with sensory functions such as auditory acuity.
Which type of test would the nurse perform to assess for myopia?
A. Perimetry
B. Ishihara chart
C. Jaeger card
D. Snellen eye chart
Myopia indicates nearsightedness. This is a condition in which a client cannot see distant images clearly, and the Snellen eye chart is used to measure distance vision. Perimetry is the computerized test performed to determine the degree of peripheral vision. The Rosenbaum Pocket Vision screener or a Jaeger card is the eye chart used to determine near vision. An Ishihara chart is used to determine a client’s ability to see colors.
Which of the following labs should the nurse expect to see elevated in the newly diagnosed client with Rheumatoid Arthritis (RA)?
A. CBC, HCG, CK-MB.
B. ESR, ANA, RF.
C. CMP, CD4, Killer T Cells.
D. WBC, Ferritin, Factor VIII.
The Erythrocyte Sedimentation Rate (ESR) confirms inflammation (non-specific), Anti-nuclear Antibody (ANA) measures the titer of a group of antibodies that destroy the nuclei of the cell, and the Rheumatoid Factor (RF) is an antibody produced by the immune system that can attack healthy tissues, and it is commonly associated with autoimmune diseases, particularly rheumatoid arthritis.
Which statement indicates that the client has a correct understanding of the condition after the nurse has finished teaching a client about sickle cell anemia?
A. "I have abnormal platelets."
B. "I have abnormal hemoglobin."
C. "I have abnormal hematocrit."
D. "I have abnormal white blood cells."
The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. The disorder affects hemoglobin rather than platelets or white blood cells. Although it can affect hematocrit, it is really a result of abnormal hemoglobin.
Which health problem history would increase an older adult’s risk for experiencing a cerebrovascular accident (CVA)?
A. Glaucoma
B. Hypothyroidism
C. Continuous nervousness, stress
D. Transient ischemic attacks (TIAs)
TIAs are temporary neurological deficits related to cerebral hypoxia; about one third of the people who have TIAs will have a cerebrovascular accident (CVA) within 2 to 5 years. Glaucoma, hypothyroidism, and continuous nervousness are not risk factors associated with a CVA.
During an annual physical assessment, a client reports not being able to smell coffee and most foods. Which cranial nerve function would the nurse assess?
A. I
B. II
C. X
D. VII
Cranial nerve I is the olfactory nerve that concerns the sense of smell; the inability to sense odors occurs with the presence of an intracranial lesion. Cranial nerve II is the optic nerve and is concerned with sight. Cranial nerve X is the vagus nerve and is concerned with the gag reflex, supplying parasympathetic fibers to body organs, and transmitting sensory impulses from the viscera. Cranial nerve VII is the facial nerve and is concerned with facial expressions, taste, and the salivary glands.
Which condition would the nurse suspect when assessing an 11-month-old infant sitting on the parent’s lap crying and tugging at the right ear?
A. Child abuse
B. Otitis media
C. Hearing impairment
D. Upper respiratory infection
Young children who cannot verbalize the presence of pain use nonverbal behaviors to indicate discomfort; crying and tugging at a painful ear are typical behaviors of an infant with otitis media. There are no data to indicate child abuse. Tugging at the ear is not an indication that the child has a hearing problem. Tugging at the ear is specific to otitis media, not an upper respiratory infection.
A 24-year-old female patient is newly diagnosed with systemic lupus erythematosus (SLE). Which of the following symptoms would the nurse most likely expect to find during assessment?
A. Bradycardia and dry skin.
B. Photosensitivity and joint pain.
C. Weight gain and hypoglycemia.
D. Petechiae and productive cough.
SLE is an autoimmune disease that commonly affects multiple organ systems. Photosensitivity (sensitivity to sunlight causing rash) and arthralgia or arthritis (joint pain and swelling) are classic manifestations of SLE. These symptoms occur due to the immune system attacking the body's own tissues.
The nurse observes bloody expectorant after a 4-year-old child with leukemia brushed his or her teeth. Which action should the nurse take next?
A. Secure a smaller toothbrush for the child to use.
B. Document and report the incident.
C. Tell the child to be more careful when brushing the teeth.
D. Rinse the child’s mouth with half-strength hydrogen peroxide.
Because of the increased capillary fragility and decreased platelet count that accompany leukemia, even the slightest trauma can cause hemorrhage. Brushing the teeth has caused gingival bleeding, and the incident should be documented; this information may also help define the treatment plan. It is wiser to eliminate a toothbrush and use a sponge-type applicator. It cannot be assumed that a 4-year-old child will or can follow a direction to be more careful when brushing. Rinsing the child’s mouth with half-strength hydrogen peroxide could irritate the gums, causing more trauma. If oral ulcers develop, the mouth should be rinsed with an isotonic solution such as normal saline.
Which assessment finding indicates the presence of bradykinesia?
A. Intention tremor
B. Muscle flaccidity
C. Paralysis of bilateral extremities
D. Jerky spontaneous movement
Bradykinesia is a slowing down in the initiation and execution of movement, causing jerky spontaneous movements. Tremors are more prominent at rest and are known as nonintention, not intention, tremors. Cogwheel rigidity, not flaccidity, occurs because the disorder causes sustained muscle contractions. The limbs are rigid and move with a jerky quality; the limbs are not paralyzed.
Which instruction would the nurse give the client when assessing for damage to the glossopharyngeal and vagus nerves?
A. Smile
B. Shrug
C. Smell
D. Swallow
Having the client swallow or checking the gag reflex is a test of cranial nerves IX and X. Shrugging tests the accessory nerve (cranial nerve XI). The sense of smell tests the olfactory nerve (cranial nerve I). Smiling tests the facial nerve (cranial nerve VII).
Which medication is a beta-adrenergic blocker used to reduce intraocular pressure?
A. Timolol
B. Travoprost
C. Carbachol
D. Apraclonidine
Glaucoma is manifested by increased intraocular pressure. Timolol is a beta-adrenergic blocker used in the treatment of glaucoma. Travoprost is a prostaglandin agonist, and apraclonidine is an adrenergic agonist used in the treatment of glaucoma. Carbachol is a cholinergic agonist used to treat glaucoma.
A nurse is assessing a patient diagnosed with scleroderma. Which of the following findings is most characteristic of this condition?
A. Hypermobile joints and easy bruising
B. Thickened, hardened skin and Raynaud’s phenomenon
C. Alopecia and butterfly-shaped facial rash
D. Enlarged lymph nodes and night sweats
Scleroderma, or systemic sclerosis, is a chronic autoimmune disease characterized by fibrosis of the skin and internal organs. A hallmark feature is skin thickening and tightening, especially of the hands and face. Raynaud’s phenomenon, which involves episodic vasospasm of the fingers and toes in response to cold or stress, is also common and often one of the earliest signs.
Which finding would be most important to communicate to the health care provider when the nurse is assessing a 20-year-old client who has come to the clinic reporting recent unintended weight loss and fatigue?
A. Pallor of skin
B. Heart rate 98 beats/minute
C. Cool feet and decreased pedal pulses
D. Nontender enlarged cervical lymph node
Nontender and enlarged lymph nodes in a 20-year-old client suggest possible Hodgkin lymphoma, especially with the client’s history of unintended weight loss. The client is likely to be scheduled quickly for a lymph node biopsy. The other findings would be reported to the health care provider, but do not indicate a need for rapid action. Skin pallor may be associated with anemia or may be normal for the client. Heart rate is in the upper range of normal for an adult. Cold feet and decreased pedal pulses may be caused by anxiety or because the examination room is cold.
Which information would the nurse consider when planning care for a group of clients with myasthenia gravis and amyotrophic lateral sclerosis (ALS)?
A. Progressive deterioration until death
B. Increased risk for respiratory complications
C. Involuntary twitching of small muscle groups
D. Deficiencies of essential neurotransmitters
Both share increased risk for respiratory complications. As a result of muscle weakness, the vital capacity is reduced, leading to increased risk of respiratory complications; impaired swallowing can also lead to aspiration. Although ALS is progressive, clients with myasthenia gravis may be stable with treatment. Neither of these diseases are caused by a lack of neurotransmitters; only myasthenia gravis is associated with a decreased number of receptor sites. Twitching is not expected with myasthenia gravis.
Which equipment would the nurse need to obtain to assess the client’s vagus nerve (cranial nerve X)?
A. Tuning fork
B. Ophthalmoscope
C. Tongue depressor
D. Cotton ball
A tongue depressor is used to depress the tongue to observe the pharynx and larynx and to assess soft palate symmetry and the presence of the gag reflex; the information obtained provides data about cranial nerve X ( vagus). A tuning fork is used to assess cranial nerve VIII (auditory). An ophthalmoscope is used to assess cranial nerve II (optic). Cotton is used to assess sensory function: light touch.
Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss?
A. Smiling while seeing the client
B. Nodding head in front of the client
C. Making eye contact with the client
D. Leaning forward towards the client
The nurse would make eye contact with the client to show interest in starting a conversation with a client with hearing loss. Smiling while seeing the client would help build a positive relationship. Nodding in front of the client helps regulate the conversation. Leaning forward towards the client shows attention and awareness.
A nurse is caring for a patient with chronic gout who has been prescribed allopurinol. Which of the following statements by the patient indicates a need for further teaching?
A. “I will take this medication with food to reduce stomach upset.”
B. “I should drink plenty of fluids while taking this medication.”
C. “I’ll take this medication when I feel a gout attack starting.”
D. “This medication helps lower the uric acid level in my blood.”
Allopurinol is a xanthine oxidase inhibitor used to lower serum uric acid levels in patients with chronic gout. It is not intended for use during an acute gout attack, as it does not relieve pain or inflammation and may even worsen the attack if started during a flare. It is used long-term to prevent future attacks.
Which finding will be most important to communicate to the health care provider when the nurse is assessing a client with osteolytic lesions caused by multiple myeloma?
A. Bruising at injection sites
B. Calcium level 10.2 mg/dL (2.55 mmol/L)
C. New onset weakness in both legs
D. Elevated urine protein level
Because osteolytic lesions can lead to pathologic fractures, including vertebral collapse and pressure on the client’s spinal cord, the nurse would immediately report new onset leg weakness to the health care provider. The other findings are associated with multiple myeloma, but do not indicate a need for immediate action to prevent complications. Bruising at injection sites is likely because of thrombocytopenia caused by the disease process or by chemotherapy. The client’s serum calcium level is normal, but calcium levels are monitored because osteolysis can cause hypercalcemia. Urine protein levels are elevated because of the high level of abnormal Bence-Jones protein seen with multiple myeloma.
A client asks the nurse what causes Parkinson disease. Which description of pathology would the nurse provide in response to the client?
A. Disintegration of the myelin sheath
B. Breakdown of upper and lower neurons
C. Reduced acetylcholine receptors at synapses
D. Degeneration of neurons of the basal ganglia
Parkinson disease involves destruction of the neurons of the substantia nigra, reducing dopamine. The cause of this destruction is unknown. Disintegration of the myelin sheath is associated with multiple sclerosis. Breakdown of upper and lower motor neurons is associated with Lou Gehrig disease, or amyotrophic lateral sclerosis. Reduced acetylcholine receptors at synapses are associated with myasthenia gravis.
After a head injury, a client reports hearing ringing noises. Which area would the nurse assess further?
A. Frontal lobe
B. Occipital lobe
C. Sixth cranial nerve (abducens)
D. Eighth cranial nerve (vestibulocochlear)
The eighth cranial nerve has two parts: the vestibular nerve and the cochlear nerve. Sensations of hearing are conducted by the cochlear nerve. The frontal lobe is concerned with thinking and emotions. The occipital lobe is concerned with sight, particularly shape and color. Cranial nerve VI (abducens) is concerned with abduction of the eye.
Which response reported by an older adult client would the nurse identify as consistent with the diagnosis of macular degeneration?
A. "My vision is best when I dim the lights."
B. "I always see halos around lights, especially at night."
C. "I can’t see objects in my periphery vision."
D. "I can’t see objects in the center of my vision field."
The macula is the central vision area of the retina; therefore macular degeneration affects central vision and makes objects within direct, center vision difficult to see. Dim light will make vision more difficult for this client. Seeing halos around lights relates to glaucoma, rather than macular degeneration. An inability to see objects in the periphery relates to glaucoma, rather than macular degeneration.
In which organ does the development of cellular immunity occur?
A. Bursa equivalent lymphoid tissue
B. Thymus gland
C. Spleen
D. Bone Marrow
The thymus gland is responsible for the differentiation and maturation of T lymphocytes, not bone marrow. Bone marrow is responsible for making lymphocytes, which ultimately travel to peripheral lymphoid organs. However, the specialization of lymphocytes into cellular immune cells occurs in the thymus gland. The spleen is the primary site for filtering foreign antigens from the blood; it does not assist in the development of cellular immunity
Which clotting factor would a nurse explain is deficient to the parents of a child newly diagnosed with hemophilia A?
A. Factor II
B. Factor XII
C. Factor IX
D. Factor VIII
Hemophilia type A, the most common type of hemophilia, is from a deficiency of Factor VIII. Factors II and XII are part of the clotting cascade, but they are not associated with hemophilia. Factor IX is associated with hemophilia type B.