665 Matching questions
- A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. Which nursing diagnosis takes highest priority in this client's plan of care?
- A patient who is seen in the outpatient clinic complains of restless legs syndrome. Which of the following over-the-counter medications that the patient is taking routinely should the nurse discuss with the patient?
- Nurses have the responsibility to dispel myths and replace stereotypes of older adults with accurate information. The nurse knows that most older adults:
- How many lumbar and sacral spinal nerves are there? What do they control?
- A client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière's disease. When assessing this client, the nurse expects to note:
- The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which of the following complications (select all that apply)?
A) Vision loss
B) Cerebral edema
C) Pituitary dysfunction
D) Parathyroid dysfunction
E) Focal neurologic deficits
- Discuss common drugs used in the treatment of Alzheimer's disease.
- 3. A male client is having a tonic-clonic seizures. What should the nurse do first?
a. Elevate the head of the bed.
b. Restrain the client's arms and legs.
c. Place a tongue blade in the client's mouth.
d. Take measures to prevent injury.
- What should be done on a post retinal detachment surgery?
- What is motor aphasia?
- Which patient is at highest risk for a spinal cord injury?
1. 18-year-old male with a prior arrest for driving while intoxicated (DWI)
2. 20-year-old female with a history of substance abuse
3. 50-year-old female with osteoporosis
4. 35-year-old male who coaches a soccer team
- Where do ulcers start?
- NSAIDs AKA Prostoglandin antagonists
- What should you document for a seizure occurrence?
- Which statement about older adults in the United States is correct?
- The culturally sensitive nurse will realize which of the following about a client from a large active Latino family who is put into isolation for a communicable disease?
1. The number of visitors greatly needs to be 2. May be accustomed to, and need, high stimulation level
3. Is a likely candidate for sensory overload
4. Will need more personal space than other clients
- When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with ______________
- The nurse assesses normal pupils in a client who had a craniotomy, and then writes "PERRLA" in the nurse's notes, along with other findings. What does the "E" stand for in this acronym?
- Mode of Action
- During the course of a busy shift, a nurse fails to document that a client's ventricular drain had an output of 150 ml. Assuming that the drain was no longer draining cerebrospinal fluid, the physician removes the drain. When the nurse arrives for work the next morning, she learns that the client became agitated during the night and his blood pressure became elevated. What action should the nurse take?
- What nursing interventions should be implemented for someone with aphasia?
- On patients with spinal cord injuries, what areas must be placed on vents?
- Which of the following is an initial sign of Parkinson's disease? 1. Rigidity. 2. Tremor. 3. Bradykinesia. 4. Akinesia.
- Stage 3
- Stage 2
- The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include ______________
- 20. The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following?
a. Giving the client thin liquids
b. Thickening liquids to the consistency of oatmeal
c. Placing food on the unaffected side of the mouth
d. Allowing plenty of time for chewing and swallowing
- Hearing Loss Hesi Hint #1
- The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit?
- When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best?
- Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care?
- Which of the following is the priority nursing diagnosis for the patient who has undergone surgery for a spinal fusion?
1. Acute Pain
2. Impaired Mobility
3. Risk for Infection
4. Risk for Injury
- The nurse discusses the possibility of a client's attending day treatment for clients with early Alzheimer's disease. Which of the following is the best rationale for encouraging day treatment?
1. The client would have more structure to his day.
2. Staff are excellent in the treatment they offer clients.
3. The client would benefit from increased social interaction.
4. The family would have more time to engage in their daily activities.
- charge nurse you are making assignments, pulled from pacu for the day
- The nurse observes that a comatose client's response to painful stimuli is decerebrate posturing. The client exhibits extended and pronated arms, flexed wrists with palms facing backward, and rigid legs extended with plantar flexion. Decerebrate posturing as a response to pain indicates:
- What measures should the nurse encourage female clients to take to prevent osteoporosis?
- Discuss the nursing measures in a bowel/bladder training program.
- What lid is the correct way to administer Eyedrops? What is the sequential order?
- Phenytoin (Dilantin)
- (SELECT ALL THAT APPLY) The nurse is planning care for a client with multiple sclerosis. Which problems should the nurse expect the client to experience?
- While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when she uses vulgar language with him. The nurse should:
1. Tell her that she is very rude.
2. Ignore the vulgarity and distract her.
3. Tell her to stop swearing immediately.
4. Say nothing and leave the room.
- When dealing with safety in a PD patient, what should one tell them?
- Recognize the patient/family's ability to adapt to role changes.
- A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse implement first?
- Conductive Hearing Loss
- An elderly woman's husband died. When her brother arrives for the funeral, he notices her short-term memory problems and occasional disorientation. A few weeks later, she calls him to say that her husband just died. She says, "I didn't know he was so sick. Why did he die now?" She also complains of not sleeping, urinary frequency and burning, and seeing rats in the kitchen. A home care nurse is sent to evaluate her situation and finds the woman reclusive and passive, but pleasant. The nurse calls the woman's primary care physician to discuss the client's situation and background, and give his assessment and recommendations. The nurse concludes that the woman:
1. Is experiencing the onset of Alzheimer's disease.
2. Is having trouble adjusting to living alone without her husband.
3. Is having delayed grieving related to her Alzheimer's disease.
4. Is experiencing delirium and a urinary tract infection.
- A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation?
- Explain the emergency care for a patient experiencing a CVA.
- 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.
- When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should _____________
- What are the classifications of the commonly prescribed eye drops for glaucoma?
- cheyne stokes
- A hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may have had a stroke (CVA). What is the nurse's priority intervention?
1. Move the patient to the critical care unit.
2. Assess blood pressure.
3. Assess the airway and breathing.
4. Observe urinary output.
- The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply. 1. Restrict fluids to 1,000 mL/ 24 hours. 2. Drink 400 to 500 mL with each meal. 3. Drink fluids midmorning, midafternoon, and late afternoon. 4. Attempt to void at least every 2 hours. 5. Use intermittent catheterization as needed.
- In responding to visceral stimuli, the client would be most likely to experience which of the following?
1. Being aware train is coming because of hearing whistle
2. Being aware of which foot is forward when walking
3. Awareness of a full stomach
4. Being aware of an unpleasant smell
- A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse notes that the client takes benztropine (Cogentin), 0.5 mg by mouth daily, and asks when the client takes the drug each day. Which response indicates that the client understands when to take benztropine?
- Parietal Lobe
- A hospitalized client is disoriented and believes she is in a train station. Which response from the nurse is the most appropriate?
1. "You wouldn't be getting a bath at the train station."
2. "Let's finish your bath before the train arrives."
3. "Don't you know where you are?"
4. "It may seem like a train station sometimes, but this is Hogwarts."
- The nursing diagnosis Risk for Impaired Skin Integrity related to sensory-perceptual disturbance would best fit a client who:
1. Cut a foot by stepping on broken glass.
2. Uses a wheelchair due to paraplegia.
3. Wears glasses because of poor vision.
4. Is legally blind and smokes in bed.
- After receiving change-of-shift report on the following four patients, which patient should the nurse see first?
- A client experienced bradycardia during electroconvulsive therapy (ECT) treatment. A nurse assigns a nursing diagnosis of decreased cardiac output R/T vagal stimulation occurring during ECT. Which outcome would the nurse expect the client to achieve?
A. The client will verbalize an understanding of the need for moving slowly after treatment.
B. The client will maintain an oxygen saturation level of 88% 1 hour after treatment.
C. The client will continue adequate tissue perfusion 1 hour after treatment.
D. The client will verbalize an understanding of common side effects of ECT.
- A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?
- Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis? 1. Rolling the client onto the side. 2. Sliding the client to move up in bed. 3. Lifting the client when moving the client up in bed. 4. Having the client help lift off the bed using a trapeze.
- What is a normal eye pressure? What device is used?
- Describe common diagnostic tests for the patient with neurological manifestations.
- gag reflex
- What is characteristic of a left hemisphere CVA?
- An internal corneal reflex would be demonstrated by which of the following?
A. a bilateral blink
B. a bilateral pupillary constriction
C. a bilateral horizontal deviation of the eye
D. bilateral tearing
- What makes someone with myasthenia gravis worse?
- Carbamazepine (Tegretol)
- Intracranial Pressure Monitoring (ICP)
- A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, "Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment." Which of the following responses by the nurse is most appropriate?
1. "Please come away from the door. I'll show you your room."
2. "It's Tuesday and you are in the hospital. I'm Anne, a nurse."
3. "The door is locked to keep you from getting lost."
4. "I want you to come eat your lunch before you go the doctor."
- The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. Myasthenia gravis is associated with:
- Advantages and Disadvantages
- A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
- A nurse should recognize that electroconvulsive therapy (ECT) would potentially improve the symptoms of clients with which of the following Axis I diagnoses? (Select all that apply.)
A. Major depressive disorder
B. Bipolar disorder: manic phase
C. Schizoaffective disorder
D. Obsessive-compulsive anxiety disorder
E. Body dysmorphic disorder
- What is PARKINSON'S DISEASE?
- (SELECT ALL THAT APPLY) The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions should be included in the client's care plan?
- What are symptoms of stroke?
- Visual acuity declines with age. Presbyopia is a progressive decline in:
- What are the risk factors for Guillain Barre Syndrome?
- Examine health promotion techniques and available resources for the patient with a head injury.
- A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?
1. Administer PRN haloperidol (Haldol) to decrease the need to walk.
2. Assess the client's gait for steadiness.
3. Restrain the client in a geriatric chair.
4. Administer PRN lorazepam (Ativan) to provide sedation.
- A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
- More about pharmacokinetics and complex kinetics of phenytoin
- What is autonomic dysreflexia? What is the cause? What are the signs and symptoms?
- Describe nursing care for the client who is experiencing phantom pain after amputation.
- Which statement by a client with a seizure disorder taking topiramate (Topamax) indicates the client has understood the nurse's instruction? 1. "I will take the medicine before going to bed." 2. "I will drink 6 to 8 glasses of water a day." 3. "I will eat plenty of fresh fruits." 4. "I will take the medicine with a meal or snack."
- Advantages of Gabapentoin
- To enhance effectiveness in teaching the older adult, the nurse should:
- A patient whose status is post-stroke (CVA) has severe right-sided weakness. Physical therapy recommends a quad cane. Which of the following is proper use of the cane by the patient?
1. The patient holds the cane in the left hand. The patient moves the cane forward first, then the right leg, and then the left leg.
2. The cane is held in either hand and moved forward at the same time as the left leg. Then the patient drags the right leg forward.
3. The patient holds the cane in the right hand for support. The patient moves the cane forward first, then the left leg, and then the right leg.
4. The patient holds the cane in the left hand. The patient moves the left leg forward first, then moves the cane and the right leg forward together.
- Peripheral neuropathy and paresthesias become the etiology for other nursing diagnoses. An example of such a diagnosis is:
1. Risk for injury
2. Impaired swallowing
3. Fluid volume overload
4. Social isolation
- The nurse is assessing a patient who is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action?
- 11. Nurse Maureen witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to opens the airway in this victim by using which method?
a. Flexed position
b. Head tilt-chin lift
c. Jaw thrust maneuver
d. Modified head tilt-chin lift
- A nurse on the neurologic unit evaluates her client care assignment after receiving the shift report. Which client in her assignment should she attend to first?
- S/E of all AEDs
- Adverse effects of Topirimate
- A client who experienced a severe stroke develops a fever and a cough that produces thick, yellow sputum. A nurse observes sediment in the client's urine in the indwelling urinary catheter tubing. Based on these findings, which action should the nurse take?
- What should you teach your patient about TENS therapy?
- Identify specific medications and usage for various sign/symptoms of MS.
- Differentiate between RF and osteoarthritis in terms of joint involvement.
- How can someone with a C1-C4 injury maintain some independence?
- A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take?
- Discuss assessment methods used to identify changes in patient neurological status?
- Discuss the etiology of seizures.
- When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because: 1. Physical dependency on the drug develops over time. 2. Status epilepticus may develop. 3. A hypoglycemic reaction develops. 4. Heart block is likely to develop.
- A patient with mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication?
- In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because? 1. The rehabilitation plan will be guided by it. 2. Functional status before the stroke will help predict outcomes. 3. It will help the client recognize his physical limitations. 4. The client can be expected to regain much of his functioning.
- The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider?
1. Paradoxical excitement.
3. Slowing of reflexes.
- A client recovering from a stroke has right-sided hemiplegia and telegraphic speech and often seems frustrated and agitated, especially when trying to communicate. However, the chart indicates that the client's auditory and reading comprehension are intact. The nurse suspects that the client has:
- When comparing air conduction vs. bone conduction, which is expected to occur?
A. bone conduction is normally 2 times as long as air conduction
B. bone conduction and air conduction are equal
C. air conduction is normally 3 times as long as bone conduction
D. air conduction is normally 2 times as long as bone conduction
- Describe postop residual lib care after amputation for the first 48 hours?
- Pedi HH #1
- If the unit alarm on a negative pressure system indicates a lack of seal what should you do?
- RF Hesi Hint #2
- Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
- Lamotrigine (Lamictal)
- What is myasthenia gravis?
- What is the third cranial nerve? Normal response?
- A new medication regimen is ordered for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken? 1. At bedtime. 2. All at one time. 3. Two hours before mealtime. 4. At the time scheduled.
- 16. A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH of 6
c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings and test positive of glucose
- A client with impaired vision is admitted to the hospital. Which interventions are most appropriate to meet the client's needs? Select all that apply.
1. Identify yourself by name.
2. Decrease background noise before speaking.
3. Stay in the client's field of vision.
4. Explain the sounds in the environment.
5. Keep your voice at the same level throughout the conversation.
- The nurse is performing a mental status examination on a client diagnosed with a subdural hematoma. This test assesses which of the following functions?
- When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?
1. Cancer of any kind.
2. Impaired hearing.
3. Prescription drug intoxication.
4. Heart failure.
- A nurse is caring for a group of clients on the neurologic unit. Which task should the nurse perform first?
- Amputation Hesi Hint #1
- Explain the nursing care of the patient with a CVA.
- A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis?
- Aricept (donepezil)
- What are the signs and symptoms of risk factors for retinal detachment?
- A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that ______________
- Sexuality is recognized as a factor in the care of older adults, thus:
- List common signs and symptoms of head injury.
- What should the nurse do when administering pilocarpine (Pilocar)?
- A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for __________
- Which two factors contribute to the projected increase in the number of older adults?
- During a course of 12 electroconvulsive therapy (ECT) treatments, an anxious client diagnosed with major depression refuses to bathe or attend group therapy. At this time, which of the following nursing diagnoses should be assigned to this client? (Select all that apply.)
A. Anxiety R/T post-ECT confusion and memory loss
B. Risk for injury R/T post-ECT confusion and memory loss
C. Disturbed thought processes R/T post-ECT confusion and memory loss
D. Altered sensory perception R/T post-ECT confusion and memory loss
E. Social isolation R/T post-ECT confusion and memory loss
- A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
- What is the correct way to help someone with a CVA get out of bed?
- Fracture Hesi Hint #1
- The nurse is teaching a client and his family about baclofen (Lioresal) therapy. Baclofen is an analogue of which neurotransmitter?
- Which statement indicates the client needs a sensory aid in the home?
1. "I tripped over that throw rug again."
2. "I can't hear the doorbell."
3. "My eyesight is good if I wear my glasses."
4. "I can hear the TV if I turn it up high."
- List three problems associated with immobility.
- What is retinal detachment?
- How do you describe a RETINAL DETACHMENT vision?
- What is characteristic of a Stage II pressure ulcer?
- What is the seventh cranial nerve? Normal response?
- When helping the families of clients with Alzheimer's disease cope with vulgar or sexual behaviors, which of the following suggestions is most helpful?
1. Ignore the behaviors, but try to identify the underlying need for the behaviors.
2. Give feedback on the inappropriateness of the behaviors.
3. Employ anger management strategies.
4. Administer the prescribed risperidone (Risperdal).
- Describe the role of the nurse in the community setting.
- The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:
- What are the risk factors for GLAUCOMA?
- Compare the symptoms of PDD, Autism and Down syndrome.
- Epilepsy syndromes
- Older adults experience a change in sexual activity. Which best explains this change?
- What is the sixth cranial nerve? Normal response?
- Which information about a patient who is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease is most important for the nurse to report to the health care provider?
- What is characteristic of a Stage IV pressure ulcer?
- Discuss a teaching plan for the child with a head injury.
- 21. The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:
a. Gets angry with family if they interrupt a task
b. Experiences bouts of depression and irritability
c. Has difficulty with using modified feeding utensils
d. Consistently uses adaptive equipment in dressing self
- babinksi reflex
- Discuss common causes of a head injury.
- What is the eighth cranial nerve? Normal response?
- 12. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain?
a. Sternal rub
b. Nail bed pressure
c. Pressure on the orbital rim
d. Squeezing of the sternocleidomastoid muscle
- Somatic Nervous System
- What is the purpose of a TENS system?
- Fracture Hesi Hint #6
- Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures?
- The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
- A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as _______
- What are the immediate nursing actions if fat embolization is suspected in a client with a fracture or other orthopedic condition?
- Prodromal manifestations prior to an intracranial aneurysm rupture could be recognized by the nurse as which of the following?
Select all that apply.
1. visual deficits
3. mild nausea
4. dilated pupil
5. stiff neck
- 26. The nurse has given the male client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will:
a. Exposure to cold and drafts
b. Massage the face with a gentle upward motion
c. Perform facial exercises
d. Wrinkle the forehead, blow out the cheeks, and whistle
- How is multiple sclerosis treated?
- During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Temperature.
- An 83-year-old woman is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory tests and X-rays done that day. The grandson says, "She has already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest." The nurse should tell the grandson which of the following? Select all that apply.
1. "I agree she needs to rest, but there is no one specific medicine for your grandmother's condition."
2. "The doctor will look at the results of those tests in the ED and decide what other tests are needed."
3. "Delirium commonly results from underlying medical causes that we need to identify and correct."
4. "Tell me about your grandmother's behaviors and maybe I could figure out what medicine she needs."
5. "I'll ask the doctor to postpone more tests until tomorrow."
- 8. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care?
a. Disturbed sensory perception (visual)
b. Self-care deficient: Dressing/grooming
c. Impaired verbal communication
d. Risk for injury
- A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to _______________
- Which action should the nurse take when assessing a patient with trigeminal neuralgia?
- A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly?
1. autonomic dysreflexia
2. autonomic crisis
3. autonomic shutdown
4. autonomic failure
- Valproic acid (Depakote, Depacon)
- When communicating with a client who has aphasia, which of the following nursing interventions is not appropriate? 1. Present one thought at a time. 2. Encourage the client not to write messages. 3. Speak with normal volume. 4. Make use of gestures.
- The nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?
- What causes tremors?
- The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care?
- A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?
- What is sensory aphasia?
- How does GBS progress?
- What are the non-reversible risk factors for CVA?
- When might a deep tendon reflex be more than 2?
- Discuss Glasgow Coma scale.
- A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough violently. What should the nurse do?
- What are the five stages of involvement in PD patients?
- A quadriplegic client is prescribed baclofen (Lioresal), 5 mg by mouth three times daily. What is the principal indication for baclofen?
- When teaching a client about levodopa and carbidopa (Sinemet) therapy for Parkinson's disease, the nurse should include which instruction?
- Steroid Hesi Hint**
- A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:
- Discuss drugs used to treat seizures by: name, action, adverse reactions and special precautions.
- Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium), 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?
- Differentiate between MS, Myasthenia, and ALS.
- In addition to developing over a period of hours or days, the nurse should assess delirium as distinguishable by which of the following characteristics?
1. Disturbances in cognition and consciousness that fluctuate during the day.
2. The failure to identify objects despite intact sensory functions.
3. Significant impairment in social or occupational functioning over time.
4. Memory impairment to the degree of being called amnesia.
- Describe the criteria for determining dosage of anticoagulant drugs. (PT, INR, APTT)
- For a client with suspected increased intracranial pressure (ICP), the most appropriate respiratory goal is to:
- Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. 1. Carefully test the temperature of bath water. 2. Avoid kitchen activities because of the risk of injury. 3. Avoid hot water bottles and heating pads. 4. Inspect the skin daily for injury or pressure points. 5. Wear warm clothing when outside in cold temperatures.
- A client scheduled for electroconvulsive therapy (ECT) at 9:00 a.m. is discovered eating breakfast at 8:00 a.m. Based on this observation, which is the most appropriate nursing action?
A. The nurse notifies the client's physician of the situation and cancels the ECT.
B. The nurse removes the breakfast tray and assists the client to the ECT treatment room.
C. The nurse allows the client to finish breakfast and reschedules ECT for 10:00 a.m.
D. The nurse increases the client's fluid intake to facilitate the digestive process.
- caring for a client w an external fixator on the lower leg for a fractured tibia, complication
- Deep brain stimulation
- 4. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
a. "You may have difficulty believing this, but the paralysis caused by this disease is temporary."
b. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss."
c. "It must be hard to accept the permanency of your paralysis."
d. "You'll first regain use of your legs and then your arms."
- mutliple sclerosis
- What should you teach a patient about managing GLAUCOMA?
- Discuss the community resources available to the patient with a neuromuscular disorder.
- Clients admitted into the emergency department may experience behavior changes due to:
2. Sensory reception
4. Sensory overload
- A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient?
- Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. What action is best for the nurse to take?
- What are the risk factors for PD (7)
- Discuss alternative communication methods with an aphasic patient.
- If a patient with CVA is getting dressed which side should they address first?
- The nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?
- Kyphosis, a change in the musculoskeletal system, leads to:
- Status epilepticus management
- Why are fractures of the epiphyseal plate a special concern?
- Discuss the nursing implications for medications ordered for patients with a spinal cord injury.
- When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?
- (SELECT ALL THAT APPLY) The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate that he understands the instructions?
- What should you do immediately for someone suspected of subarachnoid hemorrhage?
- When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?
- To evaluate a client's cranial nerve function, the nurse should assess:
- For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1. Speaking loudly. 2. Using a picture board. 3. Writing directions so client can read them. 4. Speaking in short sentences.
- The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client is:
- Explain the importance of frequent neuro vital signs in the early phase of neurological injury.
- observe the nursing assistant performing all of these interventions for the pt with CTS
- The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? 1. Placing a pillow in the axilla so the arm is away from the body. 2. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow. 3. Immobilizing the extremity in a sling. 4. Positioning a hand cone in the hand so the fingers are barely flexed. 5. Keeping the arm at the side using a pillow.
- Cranial Nerve III
- Ketogenic diet
- which pts
- what it is
- Describe two classifications of drugs used to treat a TIA.
- How many thoracic spinal nerves are there? What do they control?
- A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
- Describe the use of clinical pathway/care map to guide the care of the patient with a CVA.
- When administering a mental status examination to a patient with delirium, the nurse should _____________
- What are the signs and symptoms of multiple sclerosis?
- skin around pin site is swollen red and crusty with dried drainage
- What is the treatment for Meniere's disease?
- Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient?
- A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about ____________
- A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
- Nurses can increase environmental stimuli for clients with sensory deficit by:
1. Keeping the radio on throughout the day to provide auditory stimulation
2. Keeping the bathroom light on at night to avoid complete darkness
3. Establishing a routine identified with each meal
4. Ensuring the client's safety
- Cranial Nerve IV
- What is characteristic of a right hemisphere CVA?
- A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate for the nurse to include in patient and family teaching?
Select all that apply.
1. how to use a sign board
2. transfer techniques
3. information about impulse control
4. time adjustment to complete activities
5. safety precautions for transferring
- Fracture Hesi Hint #3
- The physician prescribes diazepam (Valium), 10 mg I.V., for a client experiencing status epilepticus. Which statement about I.V. diazepam is true?
- A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?
- What drug is commonly taken to help Parkinson's symptoms? What are the Considerations?
- A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/ 88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? 1. Suction the airway 2.hyperoxygenate 3.suction the mouth 4. Provide sedation
- The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement?
- What does hemiplegia mean? What are the considerations?
- Sensory deficit
- List normal findings in a neurovascular assessment.
- What is ELASE?
- Ethosuximide (Zarontin)
- medulla - stem
- Osteoporosis Hesi Hint #1
- When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to ____________
- Identify terms describing level of consciousness (LOC).
- What are the two types of GLAUCOMA?
The primary organ of bowel elimination is...
The gastrointestinal tract is also known as...
Waste products of digestion is called
True or False: The ileocecal (aka ileocolic) valve is the connection between the ileum of the small intesitne and the large intestine
The large intestine in adults is approximately how long?
The _____ is the first part of the large intestine
From the cecum, the digestive contects travel through the colon, which consists of several segments. Cecum --> _____ colon ---> ______ _____ (turn) ---> _____ colon ---> _____ _____ (turn) ---> ____ colon --> _____ colon
The colon is enervated by the _________ nervous system
Which of the following is true
The sympathetic nervous system promotes movements relating to bowel
The parasympathetic nervous system inhibits movements relating to bowel
Peristalsis is the contractions of circular and longitudinal muscles of the intestine and occur every 3 to 12 minutes
Hemorrhoids are if the arteries in the rectum become abnormally distended
_________ often occurs after food has been ingested, accounting for the urge to defecate that often occurs after meals.
Which of the following is the definition of intestinal gas?
Which sphincter is under conscious/voluntary control?
What refers to the emptying of te large intestine?
Which of the following is not a muscle used to create pressure in aiding in defecation?
What is the term used to descibe the technique of "bearing down" when passing a bowel movement?
True or False:A psychological variable in bowel elimination is: age affects what a person eats and the body's ability to digest nutrients and eliminate wastes.
Is the stool from formula milk or breast milk more likely to be brown?
Which of the following is true?
Breast-fed infants usually pass 1-2 stools per day
Bottle-fed infants usually pass 2-10 stools per day
Daytime bowel control is normally attained by 30 months
Psychological maturity is the first priority for successful bowel training
At what age are the internal and external anal sphincters fully developed, leading to the voluntary control of defecation?
Which of the following accurately describe constipation?
Changes in place can lead to consitpation
When the feces remain in the rectum, water is reabsorbed, makming the stool hard
Constipation is often a chronic problem for older adults
Dietary manipulation is the initial treatment for constipation
______ foods increase the bulk in fecal material. Bulkier feces increase pressure on the intestinal wall, which serves as a stiimulus for peristalsis.
Certain fruits and vegetables, bran, chocolate, alcohol, and coffee have a...
Anxiety is correlated to____; whereas chronic worry is correlated with _____
Medication with the potential to cause gastrointestinal bleeding (e.g. anticoagulants, aspirin, etc) may cause the stool to appear:
What type of medication may result in a white discoloration or speckling of stool?
In what order should one perform an abdominal assessment?
Inspection, auscultation, percussion, palpation
Inspection, percussion, auscultation, palpation
Inspection, percussion, palpation, auscultation
Percussion, palpation, auscultation, inspection
Auscultation, inspection, percussion, palpation
True or False: Paralytic ileus is the direct manipulation of bowel to temporarily inhibit perstalsis. Lasts from 12-24 hours.
A typical range for bowel sounds is 5 - ___ per minute, depending on the rate of peristalsis.
Bowel sounds are descibed as audible, inaudible, ______, __________.
When optaining a stool specimen, observe _________ aspetic techniques.
______ in stool is blood that his hidden in the specimen or cannot be seen on gross examination. Can be deteced with simple screening tests.
What colour stool intdicate upper gastrointestinal bleeding, such as from a peptic ulcer.
Bright-red blood in stool is an indicator of __________ bleeding, such as from _________ or polyps.
Upper gastrointestinal; peptic ulcer
Lower gastrointestinal; peptic ulcer
Upper gastrointestinal; hemorrhoids
Lower gastrointestinal; hemorrhoids
Upper gastrointestinal; hernia
When preserving a specimen en-route to the laboratory, the most efficient method is:
_________ is the visual examination of the large intestine from the anus to the ileocecal valve.
_______ is the direct visual examination of body organs or cavities.
________ is the visual examination fo the sigmoid colon, the rectum, and the anal canal.
_________ is the visual examination of the esophagus, the stomach, and the duodenum.
What is used to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumours, strictures, or other lesions.
___ ____ ___ tests are used to detect gastrointestinal bleeding
What type of examination is useful in also obtaining a biopsy tissue sample?
When seating a patient in bed to use a bed pan, situate the head of the bed between ____ and ____ degrees.