Altered Perception

Question 1

(For questions 1-5 please refer to the scenario below)
Based on the CT results, which of the following signs and symptoms should the nurse expect? SATA

a. Aphasia (language use or comprehension difficulty)
b. Right hemiplegia or hemiparesis
c. Unawareness of deficits
d. Impulse-control difficulty
e. Slow, cautious behavior
f. Left hemiplegia or hemiparesis
g. Visual changes or visual neglect such as hemianopsia

Answer 1

c. Unawareness of deficits
d. Impulse-control difficulty
f. Left hemiplegia or hemiparesis
g. Visual changes or visual neglect such as hemianopsia

Question 2

(For questions 1-5 please refer to the scenario below)
In planning care for the patient, what would the nurse consider appropriate for this client?

a. place objects on the client’s right side
b. place objects on the client’s left side
c. on either side since the client does not mind
d. dress the client on the unaffected side first

Answer 2

a. place objects on the client’s right side

Question 3

(For questions 1-5 please refer to the scenario below)
When the client resumes dietary intake, which of the following actions should the nurse take? SATA

a. Give the client thin liquids
b. Encourage the client to converse while eating
c. Thicken liquids to the consistency of oatmeal
d. Place food on the unaafected side of the mouth
e. Allow plenty of time for chewing and swallowing
f. Teach the client to swallow with the chin to chest slightly flexed forward

Answer 3

c. Thicken liquids to the consistency of oatmeal
d. Place food on the unaafected side of the mouth
e. Allow plenty of time for chewing and swallowing
f. Teach the client to swallow with the chin to chest slightly flexed forward

Question 4

(For questions 1-5 please refer to the scenario below)
Is the client a candidate for thrombolytic therapy?

a. Yes
b. No

Answer 4

a. Yes

Question 5

(For questions 1-5 please refer to the scenario below)
As a nurse, you would observe the client for signs of increased ICP. Which of the following client behaviors suggest an increase in ICP? SATA

a. Severe headache
b. Motor, verbal, and eye opening responses to deep pain only
c. Pupils equal at 5mm and reactive to bright light
d. Blood pressure 140/70, heart rate 58 beats/min
e. Shallow breaths followed by a period of apnea then deep breaths

Answer 5

a. Severe headache
b. Motor, verbal, and eye opening responses to deep pain only
e. Shallow breaths followed by a period of apnea then deep breaths

Question 6

A patient is being treated for increased intracranial pressure. What activities below should the patient avoid performing?

a. Coughing
b. Sneezing
c. Talking
d. Valsalva maneuver
e. Vomiting

Answer 6

a. Coughing
b. Sneezing
d. Valsalva maneuver
e. Vomiting

Question 7

A patient is being treated for increased intracranial pressure. What activities below should the patient avoid performing?

a. BP- 200/110, HR- 45beats/min, RR-10 breaths/min
b. BP-200/50, HR-45beats/min, RR-10breaths/min
c. BP- 200/50, HR-70beats/min, RR-18 breaths/min
d. BP-200/110, HR-45 beats/min, RR-15 breaths/min

Answer 7

b. BP-200/50, HR-45beats/min, RR-10breaths/min

Question 8

A patient’s ICP is 25mmHg with a BP of 90/45. What would be his cerebral perfusion pressure?
a. 60mmHg
b. 90mmHg
c. 35mmHg
d. 45mmHg

Answer 8

c. 35mmHg

Question 9

A patient was brought by his friends to the emergency department. They stated that they were on a rock climbing activity when the patient suddenly fell. You assessed his neurological status. When you apply a deep sternal rub, he extends his arms and legs and show no other response. What is his glasgow coma scale score?

a. 3
b. 4
c. 5
d. 6

Answer 9

b. 4

Question 10

One of the parameters to assess neurological status is the glasgow coma scale which elicit responses of:

a. eye and motor movements
b. motor and verbal movements
c. pupillary response
d. eye, verbal and motor responses

Answer 10

d. eye, verbal and motor responses

Question 11

A client was brought to ER reported to have a motor vehicular accident. As a nurse you would observe for signs of increased ICP. What is the earliest sign of increased ICP?

a. increased temperature
b. abnormal flexion
c. bradycardia
d. restlessness

Answer 11

d. restlessness

Question 12

Priority assessment findings for a client recovering from a head trauma? SATA

a. Eyes that move in the opposite direction when patient is turned?
b. Extremities that contracted to the core of the body
c. Level of consciousness that has not diminished since admission
d. Toes that fan out when the sole of the foot is stroked
e. Nuchal rigidity, cannot flex chin towards the chest

Answer 12

b. Extremities that contracted to the core of the body
d. Toes that fan out when the sole of the foot is stroked
e. Nuchal rigidity, cannot flex chin towards the chest

Question 13

Client recovering from head trauma. GCS of 14 over 2 hours ago, but now GCS is 11, what would be your initial action as the nurse?

a. proceed with morning care and feeding
b. report to health care provide immediately
c. give medications as prescribed
d. monitor vital signs every 30 minutes

Answer 13

b. report to health care provide immediately

Question 14

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?

a. The blood pressure increases from 120/54 to 136/62.
b. The patient is more difficult to arouse.
c. The patient complains of a headache at pain level 5 of a 10-point scale.
d. The patient’s apical pulse is slightly irregular.

Answer 14

b. The patient is more difficult to arouse.

Question 15

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first?

a. patient with a skull fracture whose nose is bleeding
b. elderly patient with a stroke who is confused and whose daughter is present
c. patient who is complaining of headache of 10 on a 0-10 scale and is suddenly agitated
d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

Answer 15

d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

Question 16

A client with dysphagia may experience difficulty in:

a. writing
b. focusing
c. swallowing
d. understanding

Answer 16

c. swallowing

Question 17

A client is diagnosed as having expressive aphasia. The nurse anticipates that the client will have difficulty with:

a. speaking and/or writing
b. follwoing specific instructions
c. understanding speech and/or writing
d. recognizing words for familiar objects

Answer 17

a. speaking and/or writing

Question 18

A nurse assesses a client who has episodes of autonomic dysreflexia. Which condition can cause this?

a. Lumbar spinal cord injury
b. full bladder
c. hypovolemia
d. right brain hemisphere injury

Answer 18

b. full bladder

Question 19

The healthcare provider has ordered IV Dopamine (Inotropin) for a patient in the emergency department with a spinal cord injury. The nurse determines that the drug is having the desired effect when assessment findings include

a. pulse rate of 56 beats/min
b. respiratory rate of 24 breaths/min
c. BP of 106/74
d. temperature of 96.8F

Answer 19

c. BP of 106/74

Question 20

Which clinical manifestation you interpret as presenting neurogenic shock in a patient with acute spinal cord injury?

a. Bradycardia
b. Hypertension
c. Neurogenic spasticity
d. Bounding pedal pulses

Answer 20

a. Bradycardia

Question 21

When assessing the body function of a patient with increased ICP, the nurse should initially assess

a.corneal reflex testing
b. extremity strength testing
c. pupillary reaction to light
d. circulatory and respiratory status

Answer 21

d. circulatory and respiratory status

Question 22

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply)?

a. fever
b. oriented to name only
c. narrowing pulse pressure
d. dilated right pupil > left pupil
e. decorticate posturing to painful stimulus

Answer 22

a. fever
b. oriented to name only
d. dilated right pupil > left pupil
e. decorticate posturing to painful stimulus

Question 23

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first?

a. patient with a skull fracture whose nose is bleeding
b. elderly patient with a stroke who is confused and whose daughter is present
c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale
d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

Answer 23

c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale

Question 24

When the nurse applies a painful stimulus to the trapezius area of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as

a. decorticate posturing.
b. decerebrate posturing.
c. localization of pain.
d. flexion withdrawal.

Answer 24

a. decorticate posturing.

Question 25

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse? a. The blood pressure increases from 120/54 to 136/62. b. The patient is more difficult to arouse. c. The patient complains of a headache at pain level 5 of a 10-point scale. d. The patient's apical pulse is slightly irregular.

Answer 25

b. The patient is more difficult to arouse.

Question 25

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse? a. The blood pressure increases from 120/54 to 136/62. b. The patient is more difficult to arouse. c. The patient complains of a headache at pain level 5 of a 10-point scale. d. The patient's apical pulse is slightly irregular.

Answer 25

b. The patient is more difficult to arouse.

Question 26

A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates a. high blood flow to the brain. b. normal intracranial pressure (ICP). c. impaired brain blood flow. d. adequate cerebral perfusion.

Answer 26

c. impaired brain blood flow.

Question 27

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is a. vomiting. b. headache. c. change in level of consciousness (LOC). d. sluggish pupil response to light.

Answer 27

c. change in level of consciousness (LOC).

Question 28

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 130/72, pulse 90, respirations 32 b. Blood pressure 148/78, pulse 112, respirations 28 c. Blood pressure 156/60, pulse 60, respirations 14 d. Blood pressure 110/70, pulse 120, respirations 30

Answer 28

c. Blood pressure 156/60, pulse 60, respirations 14

Question 29

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

Answer 29

d. Difficulty comprehending instructions

Question 30

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.

Answer 30

d. tissue plasminogen activator (tPA) infusion.

Question 31

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.

Answer 31

a. ask questions that the patient can answer with "yes" or "no."

Question 32

For a patient who had a right hemisphere stroke, the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

Answer 32

a. risk for injury related to denial of deficits and impulsiveness.

Question 33

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

Answer 33

c. The patient's usual blood pressure (BP) is 170/94 mm Hg.

Question 34

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? a. Complete blood count (CBC) b. Chest radiograph (Chest x-ray) c. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scan

Answer 34

d. Noncontrast computed tomography (CT) scan

Question 35

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

Answer 35

c. Disabled family coping related to inadequate understanding by patient's spouse

Question 36

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? a. autonomic dysreflexia b. autonomic crisis c. autonomic shutdown d. autonomic failure

Answer 36

a. autonomic dysreflexia

Question 37

Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury? a. Bradycardia b. Hypertension c. Neurogenic spasticity d. Bounding pedal pulses

Answer 37

a. Bradycardia

Question 38

When caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department, which action should be your first priority? a. Call respiratory therapist to prepare the mechanical ventilator b. Monitor cardiac rhythm and blood pressure. c. Immobilize the patient's head, neck, and spine. d. Transfer the patient to radiology for spinal CT.

Answer 38

c. Immobilize the patient's head, neck, and spine.

Question 39

In planning community education for prevention of spinal cord injuries, the nurse targets a. elderly men b. teenage girls c. elementary school-age children d. adolescent and young adult men

Answer 39

d. adolescent and young adult men

Question 40

Which clinical manifestation indicates a neurogenic shock in a patient with acute spinal cord injury? a. Bradycardia b. Hypertension c. Neurogenic spasticity d. Bounding pedal pulses

Answer 40

a. Bradycardia