A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rolling-type tremor. The nurse will anticipate teaching the patient about
· 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?
The charge nurse on serves an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene.
THE staff nurse has the patient deep-breathe and cough.
A patient is brought to the Emergency department by ambulance after being found uncouncious on the bathroom floor by the spouse. In admitting the patient, the nurse will first assess:
When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?
The patient is more difficult to arouse.
When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find:
The intervention that should be added to the nursing care plan in supporting nutritional intake for a patient with Parkinson’s disease is to:
Thicken liquids to make them easier to swallow
The nursing assessment that would indicate a need for suctioning a patient with Guillain-Barre who is experiencing impaired breathing patterns because of neuromuscular failure is:
Increased Pulse Rate, Adventitious Breath Sounds.
A 24-year-old patient is hospitalized with the onset of Guillain-Barre syndrome. During this phase of the patient’s illness, the most essential assessment for the nurse to carry out is:
Performing Constant evaluations of respiratory function.
A patient who is diagnosed with AIDS has had a developed Kaosi’s sarcoma tells the nurse. “I have lots of thoughts about dying. Do you think I am just being morbid?” which response by the nurse is most appropriate?
"Tell me what kind of thoughts you have about dying."
Interventions such as promotion of nutrition’s, exercise, and stress reduction should be promoted by the nurse for patient who have HIV infection, primarily because these interventions will:
Promote a feeling of well-being in the patient
The occupational health nurse will teach the nursing staff that the highest risk of acquiring HIV from an HIV-infected patient is: a needle sticks with a needle and syringe used to draw blood.
A needle stick with a needle and syringe used to draw blood.
While teaching community groups about AIDS, the nurse informs people that the most common method of transmission of the HIV virus currently is:
Sexual Contact with an infected person.
· A patient is admitted to the hospital in preparation for a splenectomy for treatment of immune thrombocytopenia purpura (ITP) asks the nurse about the benefits of the splenectomy. The nurse explains that the expected effect of the splenectomy is:
Reduce destruction of platelets by macrophages.
Which nursing intervention will be included in the care plan for a patient with ITP?
Avoid Intramuscular (IM) and subcutaneous injections
The most appropriate nursing interventions to include in the care plan for a patient with neutropenia is to:
Omit Fresh fruits or vegetables from the diet.
A patient with newly diagnosed leukemia is receiving chemotherapy. Which intervention will the nurse include in the plan of care:
teach visitors hand washing technique
In preparing discharge plans for a patient newly diagnosed with pernicious anemia, it is most important for the nurse to include information regarding:
Sufficient rest periods throughout the day
The rationale for administering injections of vitamin B12 to patients with pernicious anemia is that:
the patient may lack intrinsic factors necessary for vitamin B12 absorption
A 35-year-old man is seen in an urgent care clinic. He presents with symptoms of polychthemia vera. The laboratory value that would confirm the possible diagnosis is:
high hemoglobin level
At the end of a shift, a nurse documents the effectiveness of parent teaching concerning the transmission of hemophilia. Which of the following statements by the mother would best indicate an accurate parental perception?
Hemophilia is a genetic disorder and I am a carrier, even though I do not have the diseases.
When assessing the patient with thrombocytopenia, the nurse observes for:
petechiae on the skin and bleeding gums.
A patient with Parkinson’s disease is considering taking St. John’s Wort, an herbal remedy for depression, in addition to Sinemet and L-Dopa. The best response by the nurse would be:
herbal remedies can interfere with the effectiveness of the parkinsonian drugs
The nursing assessment that would indicate need for suctioning a patient with Guillain-Barre who is experiencing impaired breathing patterns because of neuromuscular failure:
increased pulse rate, Adventitious breathe sounds
A family member ask the nurse what would be an appropriate gift for a patient with Parkinson’s disease. The most useful gift would be:
When a patient falls to the floor is a generalized seizure, the nurse should:
cradle the head to prevent injury
In caring for the postcraniotomy patient, the nurse can help reduce ICP by:
elevating the head of the bed 30 degrees
The nurse updates the nursing care plan for a patient with amyptrophic lateral sclererosis who is uniquely prone to depression because:
Intellectual capacity is not affected
The nurse explain that neurotransmitters, which support smooth neural transmission, are:
Acetylcholine, dopamine, dendrite, epinephrine
the most reliable indicator of neurologic status is:
Level of consciousness
the patient who is stuporous, but reacts by withdraw is said to be:
The nurse documents a normal finding from the _________ as:
Downward curl of the toes
A patient with a severe head injury begins to assume a posture of extended upper extremities with extended lower extremities. Theses assessments indicate:
increasing ICP with decerebrates posturing
The nurse caring for a 90-year-old patient with a closed head injury would immediately report:
blood pressure change from 147/72 to 176/70.
In caring for a postcraniotomy patient, the the nurse can help reduce ICP by:
raise the head of bed to 30 degrees
When a patient falls to the floor in a generalized seizure, the nurse should:
cradle the head to prevent injury
The patient in the ER states that she fell and hit her head and blacked out for a while, but became alert again. Suspecting an epidural hematoma, the nurse will be diligent in the assessment of:
Increasing blood pressure
To prevent a post-lumbar puncture headache, the patient is instructed to:
The assessment indicating that mannitol therapy for cerebral edema is effective in a patient with increased ICP is:
Increased urinary output
A patient has a tonic-clonic seizure while the nurse is in the patient’s room. During the seizure , it is important for the nurse to:
Time and observe and record the details of the seizure and postictal state.
When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room? Suction tubing.
Oxygen mask, nasogastric tube, side rail pads
The nurse explains that the spinal cord extends from the brainstem to the level of which vertebra:
The health care provider prescribes phenytoin (Dilantin) for control of complex partial seizures. After the nurse has taught the patient about phenytoin , which statement indicates understand priority patient responsibilities of the of the medications?
I may need to have my blood taken frequently to check the level of the Dilantin.
When caring for a patient who has had a head injury, which assessment information is of most concern for the nurse?
The patient is more difficult to arouse·
When the nurse applies a painful stimulus to the nail bed of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as:
An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) r/t cerebral tissue swelling. The most appropriate nursing intervention for this problem is to:
Apply oxygen PRN to keep saturation at least 92%
The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to:
Document the timing and description of the seizure
A patient with leukemia has developed ulcerated mouth disease and is uncertain as to what to eat. Which of the following foods would be a good selection?
Creamed potato soup
The nurse is alarmed by a complete blood count that shows a large “shift to the left.” The nurse assesses this to mean that the cell level count of:
Neutrophils has increased by 60 percent
The nurse differentiates the passive acquired immunity means that the antibodies were:
Acquired from outside the host and instilled in the host
After experiencing a generalized tonic-clonic seizures in the classroom, an elementary school teacher is evaluated and diagnosed with idiopatich epilepsy. The patient cries and tells the nurse, “I Can not teach anymore. It will be too difficult for the students if this happens again at work.”The most appropriate nursing diagnosis for the patient is:
Ineffective role performance r/t misinformation about epilepsy
The nurse points out that the spleen’s primary function in the immune process is to:
filter microorganisms from the blood
During an initial assessment of a new patient in a walk-in- clinic, the nurse suspects that the patient might have thrombotic thrombocytopenic purpura (TTP). The assessment that has led to this conclusion is:
large irregular areas of ecchymosis
In preparing discharge plans for a patient with systemic lupus erythematosus (SLE), it is most important for the nurse to include:
Use of daily sunscreens with SPF higher than 15
The nurse is preparing a patient for a liver-spleen scan. Which of the following interventions is most important before the procedure:
Check for any allergies to contract media
An 11-year-old girl is diagnosed with idiopathic thrombocytopenia purpura (ITP). The parental statement that helps the nurse evaluation the teaching as successful is:
Our daughter should avoid drugs containing sulfonamides.
After teaching the patient about taking oral iron preparations for a moderate iron deficiencyAnemia, the nurse determines that additional instructions is needed when the patient says:
I should take the iron with orange juice about an hour before I eat.
A 52-year-old patient has a new diagnosis pernicious anemia. After teaching the patient about pernicious anemia, the nurse determines that the patient understands the disorder when the patient states:
I will need to have cobalamin (B12) injections regularly for the rest of my life.
The nurse explains that in autoimmune disease, the body identifies its own proteins as foreign matter and sets out to destroy itself:
lupus erythematosus, type 1 DM, rheumatoid arthritis
The nurse explains that the type of bone marrow translate that uses the patient’s own bone marrow is:
Fifteen minutes after a transfusion of packed red cells is started, a patient develops tachycardia and tachypena and complains of back pain and feeling warm. The nurse first action should be to:
Disconnect the transfusion and infuse normal saline
The health care provider orders transfusion with packed RBS’s for a patient who is hospitalized with severe anemia. The most important action by the nurse to prevent a transfusion reactions when administering the blood is to:
Verify the patient identification according hospital policy
Which of these assessments data obtained by the nurse when caring for a patient with Thrombocytopenia should be immediately communicated to the health care provider?
The patient is difficulty to arouse
A patient who is having a sickle cell crisis asks the nurse why the sickling causes pain. Nurse explains that the pain of sickling is caused by:
Tissue hypoxia caused by small blood vessel occlusion
A patient with sickle cell anemia is admitted to the hospital with sickle cell crisis. While caring for the patient during the crisis, it is important for the nurse to:
Evaluate the effectiveness of Opioid analgesics
A patient is admitted to the hospital with idiopathic Aplastic anemia. An appropriate collaborative Problem for the nurse to identify for the patient is:
Potential complications: hemorrhage
the most reliable indicator of neurologic status is:
Level of Consciousness
The nurse documents a normal finding from the babinski reflex as:
Downward curl of the toes
A patient with a severe head injury begins to assume a posture of extended upper extremities with extended lower extremities: the assessments indicates:
Increasing ICP with decerebrate posturing
the nurse caring for a 90 year old patient with a closed head injury would immediately report:
blood pressure change from 147/72 to 176/70
An unconscious patient has a nursing diagnosis of ineffective tissue perfussion (cerebral) related to cerebral tissue swelling. the most appropriate nursing intervention for this problem is:
raise head of bed to 45 degrees.
When the nurse applies a painful stimulus to the nailbeds of an unconscious patient responds with internal rotation, adduction, and flexion of the arms. the nurse would document this as:
A patient is brought to the emergency department (ED) by ambulance found unconscious on the bathroom floor by the spouse. In admitting the nurse would assess first:
On admission to the ER, the patient with a compression fracture at C5 can move only his head and has flaccid paralysis to all extremities. the distress family member ask if the paraplysis is permanent. The nurse's best response would be:
It's too early to tell, when spinal shock wears off, we will know more.
Which assessment would indicate the resolution of spinal shock?
Spastic involuntary movenment in affected limbs
Which technique of opening the airway in the newly admitted patient with spinal cord injury is the most approprate.
A paraplegic patient excitedly reports seeing his foot move when he was being turned. this phenomenon is best explained as:
A reflexive movement.
After spinal shock has been resolved, the indwelling catheter is removed the nurse tells the patient to expect the bladder to empty by:
Spontaneous reflexion action
a distressed family member asks about the purpose of the Gardner-Wells tongs. the most helpful explanation by the nurse would be that the gardner-well tongs:
Align the vervical vertebrae
The spinal cord-injured patient begins to have seizures, and the blood pressure rises, rapidly to 210/160. Which of the following is the thrid indicator of the dreaded syndrome of Autonomic dysreflexia:
When the nurse recognized autonomic dysreflexia in the spinal-cord injured patient, the immediate intervention should be to:
Raise the head of bed at least 45 degrees.
the nurse notes in a 2 hour post-laminectomy patient that there has been no urine output the nurse should:
Continue to monitor
the nurse considering interventions for the outcome of prevention of contractures in a spinal cord-injury patient will include:
Aply splints to the limbs.
After teaching a patient about management of migraine headache, the nurse determinds that the teaching has been effective if the patient states:
" I will try to lie down some place dark and quiet when the headache begins"
A patient dhas a tonic-clonic seizure while the nurse is in the patient's room. During the seizure, the nurse should:
time, observe and record the details of the seizure and postictal state.
the nurse witnessess a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to:
document the timing and description of the seizure.
When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should:
Question the patient about any legs weakness or spasms.
When planning care for a patient with mS who has a nursing Diagnosis of risk for activity intolerance related to extremity weakness secondary to stress, the most appropriate patient goal is:
the patient will complete ADLs without fatigue.
A patient has a new prescription for levodopa to control parkinson's disease which assessment data obtained by the nurse may indicate a need for a decrease in the dose?
the patients blood pressure is 90/46 mmHg.
a patient recovering from CVS asks the purpose of warfarin. the best response by the nurse is:
prevents formation of new cloths.
the nurse explains that a patient who has been determiners to have had a complete stroke as a result of a ruptured vessel in the left hemisphere would be classified as:
Immediately after CVA a major nursing priority is ensuring airway maintance
Acute phase of a stroke speaking ddistinelty begins to speak indistinctly and only with the great effort, but is coherent the stroke in evolution with dysarthia
Several days after a CVA the patient family asks the nurse if tPA is a drug therapy option now.
Drug must be given within 3 hours of the onset of symptoms
the nurse explains that a lumbar puncture is most helpful as a diagnosis tool for a new stroke patient because:
it can help determine if the stroke is hemorrhagic or embolic.
a patient who has suffered a hemorragic stroke is placed on a protocol of 60mg nimodipine every 4 days. The patient pulse is 82 prior to the administeration of dose. the nurse should:
Give the full dose
during the CVA phase there is a risk for falls r/t paralysis. the intervention that best protects the patient from injury is:
Keep side rails up according to agency policy
neural synapse refers to the length of time it takes for afferent neurons to carry impulses to the CNS
patient who is stuporous, but reacts to painful stimuli is:
babinski reflex normal signs
downward curl of the toes
a patient with sever head injury begins to assume a posture of flexed upper extermities with plantar-flexed lower.
increasing icp with decorticate posturing
positive brudzinskis sign
flex the hips when neck is flexed
ER pt fell hit head and blacked out for a while but became alert suspecting epidural hematoma the nurse will be dilignet in the assessment of
increasing blood pressure
CVA weakness on RIght side with impaired reasoning has CVA in the:
Left hemisphere of the cerebrum
Greastest risk for CVA is:
65 year old African-American man with HTN
period of momentary confusion, dizziness and slurred speech recovered in 2 hours. Most helpful episode would help:
auscultation of bruit over the carotid
patient with TIA placed on warfarin and has lab reports reflecting range for drug is
Pt, 35 seconds, control (normal), 20 seconds INR, 2
Updates teaching plan for post-TIA include provision for
daily dose of aspirin
pneumonia after stroke to prevent with a hemorrhagic CVA is to:
encourage forceful coughing to stimulate deep breathing
indicate fluid volume excess in patient actue phase of CVA is:
adventitious breath sounds
nurse assess that CVA is in transition to the rehabilitation phase when:
there is no futher neurologic deficits observed
Diagnosis imbalanced nutrition related to dysphagia what goal?
maintain weight of 150-155 olbs.
lacunar stroke differs from an ischemic CVA in that a lucunar CVA:
Affects the small arteries
Purpose of a stent in the carotid artery of a person with a TIA is:
to keep the artery open
supportive of the fustrated patient with expressive aphasia characterized by:
speech that sounds normal, but makes no sense, stuttering and spitting, and diffulty initiating speech.
indicate resolution of spincal shock is:
spastic involuntary movements in affected limbs.
pernicious anemia, most important info is
sufficient rest periods throughout the day.
rationale for administering injections of vit B12 to patient with pernicious anemaia is that:
the patient may lack intrinsic factors necessary for vit B12 absorption.
35 year old seen in urgent care clinic. presents with symptoms of polycthemia vera. lab values that would confirm the possible diagnosis is an extremely: