Neuro Exam Med Surg 3

1. A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? Answer: Keep the head of the bed elevated to 30 degrees. 2. A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? Answer: Unlicensed assistive personnel enter the patient’s room without a mask. 3. A patient in the emergency department with sudden- onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? Answer: The patient has atrial fibrillation and takes warfarin (Coumadin). 4. Which terms would a nurse use to document abnormal posturing in an adult with a neurological deficit? SATA Answer: Decerebrate posturing Decorticate posturing 5. Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? Answer: assessment of respiratory rate and effect. 6. When caring for a patient with a new right-sides homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? Answer: place objects needed on the patients left side 7. When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shufÒing gait, and pill rolling- type tremor, the nurse will anticipate teaching the patient about? Answer: antiparkinsonian drugs 8. The nurse will anticipate teaching a patient with a possible seizure disorder about which test? Answer: Electroencephalography (EEG) 9. The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication’s effectiveness? Answer: Intracranial pressure 10. After evacuation of an epidural hematoma, a patient’s intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? Answer: temperature 101.6 F 11. A school nurse is called after a student falls down a flight of stairs. The student is breathing, but unconsciousness. After calling the ambulance, which is the most appropriate action by the nurse? Answer: immobilize the neck. Securing the head. 12. A person who stops talking mid-sentence and has a blank stare for 5 seconds would most likely be experiencing? Answer: a petit mal seizure 13. A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UPA) who regularly work in the intensive care unit? Answer: Check capillary blood glucose level every 6 hours 14. A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? Answer: inspect the oral mucosa. 15. A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? Answer: assist with active range of motion (ROM) 16. A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? Answer: Unlicensed assistive personnel enter the patient’s room without a mask. 17. After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? Answer: A 50-year-old patient whose right pupil is 10 mm and unresponsive to light 18. An unconscious male patient has just arrived in the emergency department after a head injury caused by a motorcycle crash. Which order should the nurse question? Answer: prepare the patient for lumbar puncture. 19. The nurse is teaching regarding risk factors for stroke (CVA). The greatest risk factor is which of the following? Answer: hypertension 20. Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? Answer: Provide discharge instructions about monitoring neurologic status. 21. A nurse who works on a neurology unit just received change of shift report. Which patient will the nurse assess first? Answer: Patient with botulism who is experiencing difÏculty swallowing 22. A nurse is admitÝng a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicates neurogenic shock? Answer: hypotension, bradycardia, and warm, pink extremities. 23. A patient is admitted to the ED following a head injury. Match the nurses’ actions in order of priority in management of the patient. Use 1 for the first action and 6 for the last **** 0.67 points out of 1 given with these answers***** Confirm airway Anticipate cerebral surgery Maintain cervical spine precautions Monitor changes in neurologic status Determine the presence of ICP Establish IV access with a large bore catheter 1 5 2 6 4 3 24. The nurse managing a patient for increased ICP following a head injury. What are manifestations of increased ICP? SATA Answer: fever, oriented to person only, right pupil dilated greater than left pupil, decorticate posturing to painful stimuli. 25. How is cranial nerve III (CN lll), originated in the midbrain, assessed by the nurse for an early indication of pressure on the midbrain? Answer: test pupillary reaction to light 26. Which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid? Answer: Mannitol (Osmitrol)(25%) 27. An order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered? Answer: 3 hours after the onset of stroke symptoms 28. Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke? SATA Answer: patient whose blood pressure is 200/110, patient who receive heparin 24 hours ago 29. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic- clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? Answer: administer phenytoin (Dilantin) 200 mg PO daily 30. A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? Answer: apply intermittent pneumatic compression stockings 31. A patient with left sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? Answer: noncontract computed tomography (CT) scan 32. The classic manifestation of Parkinson’s disease are? SATA *** has a red arrow saying partial but has the full point given ** Answer: akinesia, tremor, rigidity, postural instability 33. A client with Parkinson’s disease is experiencing tremors, rigidity, and bradykinesia. The nurse anticipates that the physician will prescribe which medication to control these symptoms? Answer: Carbidopa- levodopa (Sinemet) 34. A client recovering from a craniotomy complains of a “runny nose”. Which of the following nursing actions should be immediately implemented? Answer: Notify the physician 35. Client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse would formulate which of the following nursing diagnoses for the client? Answer: Impaired physical mobility 36. The post- head injury client opens eyes to sound, has no verbal response and localized to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? Answer: GCS= 9 37. The order reads 500 mL 5% D/W in 4hr IV. The drop factor is 10 gtt/mL. Calculate the drip rate. (Round to the nearest whole number). Answer: 21 gtt/mL 38. The doctor orders penicillin V potassium oral suspension 0.5g now and 0.125g every 6 hours after initial dosing. The suspension that is available is penicillin V potassium 150mg/2mL. What volume should you administer now? What is the volume for the routine dosing? Round to the nearest tenth. Answer: Now 6.7mL Routine 1.7 mL 39. The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medications effectiveness? Answer: Intracranial pressure 40. While caring for a patient with spinal cord injuries (SCI), the nurse elevates the head of the bed, removes compression stocking, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following? Answer: elevated blood pressure 41. How should the nurse assess the patients trigeminal and facial nerve functions (CN V and VII)? Answer: touch a cotton wisp strand to the cornea 42. Which action should the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)? Answer: Withhold oral fluids and food 43. To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level? Answer: assist to plan bowel regimen 44. What should the nurse include in the rehabilitating plan for a 30-year-old with a C6 spinal cord injury (SCI)? Answer: propel a manual wheelchair on a flat surface 45. A patient is suspected of having multiple sclerosis. The neurologist orders various test. The patient’s MRI results are back and show lesions on the cerebellum and optic nerve. What signs and symptoms below would correlate with the MRI finding in a patient with multiple sclerosis? SATA Answer: blurry vision, pain when moving eyes, dysarthria, balance and coordination issues, dark spots in vison 46. During your discharge teaching to a patient with multiple sclerosis, you educate the patient on how to avoid increasing symptoms and relapses. You tell the patient to avoid: SATA Answer: infection, overexertion, stress 47. A patient is receiving interferon Beta for treatment of multiple sclerosis. As the nurse you will stress the importance of? Answer: hand hygiene and avoiding infection 48. A patient admitted with a head injury has admission vital signs of temp. 98.6 F (37 C), blood pressure 128/68, pulse 110, and respirations 26. Which of theses vital signs, if taken 1 hour after admissions, will be of most concern to the nurse? Answer: blood pressure 156/60, pulse 60, respiratory rate 14 49. When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as? Answer: decorticate posturing 50. A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which action should the nurse take ? SATA Answer: prepare for emergent intubation and mechanical ventilation Provide high-flow oxygen (100%) by non- rebreather mask Prepare to administer atropine IV Obtain baseline body temperature