last min Flashcards
The nurse cares for a 34-year-old woman after a lumbar puncture. Which action by the nurse is most appropriate?
A. Assess for drainage or bleeding from the puncture site.
B. Monitor for bladder dysfunction and bowel incontinence.
C. Maintain bed rest until lower extremities move normally.
D. Check for loss of muscle strength in the upper extremities.
A. Assess for drainage or bleeding from the puncture site.
After a lumbar puncture the nurse should monitor the puncture site for drainage or bleeding. Other assessments include headache intensity, meningeal irritation (nuchal rigidity), signs and symptoms of local trauma (e.g., hematoma, pain), neurologic signs, and vital signs. A lumbar puncture does not affect bowel or bladder function or upper extremity muscle strength. Bed rest until lower extremity movement returns is indicated for the patient after spinal anesthesia.
Awarded 1.0 points out of 1.0 possible points.
A patient with heart failure and type 1 diabetes mellitus is scheduled for a positron emission tomography (PET) of the brain. Which medication prescribed by the health care provider should the nurse expect to administer before the diagnostic study?
A. Regular insulin 6 units (SQ)
B. Furosemide (Lasix) 20 mg (IV)
C. Alprazolam (Xanax) 0.5 mg (PO)
D. Ciprofloxacin (Cipro) 500 mg (PO)
A. Regular insulin 6 units (SQ)
In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis the glial cells affected are the?
A. microglia
b. Astrocytes.
C. ependymal cells
D. Oligodendrocytes
D. Oligodendrocytes
Drugs or disease that impair the function of the extrapyramidal system may cause loss of?
A. sensations of pain and temperature
B. regulation of the automonic nervous system
C. integration of somatic and special sensory inputs
D. Automatic movements asociated with skeletal muscle activity
D. Automatic movements asociated with skeletal muscle activity
Rationale: A group of descending motor tracts carries impulses from the extrapyramidal system, which includes all motor systems (except the pyramidal system) concerned with voluntary movement. It includes descending pathways originating in the brainstem, basal ganglia, and cerebellum. The motor output exits the spinal cord by way of the ventral roots of the spinal nerves.
An obstruction of the anterior cerebral arteries will affect functions of?
A. Visual imaging
B. balane and coordination
C. Judgment, insight, and reasoning
D. Visual and auditory integration for language comprehension
C. Judgment, insight, and reasoning
Rationale: The anterior cerebral artery feeds the medial and anterior portions of the frontal lobes. The anterior portion of the frontal lobe controls higher order processes such as judgment and reasoning.
Paralysis of lateral gaze indicates a lesion of cranial nerve
A. II
B. III
C. IV
D. VI
D. VI
Rationale: Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) are responsible for eye movement. The lateral rectus eye muscle is innervated by cranial nerve VI, and it is the primary muscle that is responsible for lateral eye movement.
A result of stimulation of the parasympathetic nervous system is (select all that apply)
A. constriction of the bronchi B. Dilation of skin blood vessels C. increased secreation of insulin D. increased blood glucose levels E. relaxation of the urinary sphincters
A. constriction of the bronchi
B. Dilation of skin blood vessels
C. increased secreation of insulin
E. relaxation of the urinary sphincters
Rationale: Stimulation of the parasympathetic nervous system results in constriction of the bronchi, dilation of blood vessels to the skin, increased secretion of insulin, and relaxation of the urinary sphincter. Stimulation of the sympathetic nervous system results in increased blood glucose levels.
Assessment of muscle strength of older adults cannot be compared with that of younger adults because?
A. Stroke is more common in older adults
B. Nutritional status is better in younger adults
C. Most young people exercise more than older people
D. Aging leads to a decrease in muscle bulk and strength
D. Aging leads to a decrease in muscle bulk and strength
Rationale: Changes associated with aging include decreases in muscle strength and agility in relation to decreased muscle bulk.
Data regarding mobility, strength, coordination and activity tolerance are important for the nurse to obtain because?
A. Many neurologic diseases affect one or more of these areas
B. Patients are less able to identify other neurologic impairments
C. These are the first functions to be affected by neurologic diseases
D. Aspects of movement are the most important function of the nervous system
A. Many neurologic diseases affect one or more of these areas
Rationale: Many neurologic disorders affect the patient’s mobility, strength, and coordination. These problems can alter the patient’s usual activity and exercise patterns.
During neurologic testing, the patient is able to perceive pain elicited by pinprick based on this finding the nurse may omit testing for?
A. Position sense
B. Patellar reflexes
C. Temperature perception
D. Heel-to- shin movements
C. Temperature perception
Rationale: If pain sensation is intact, assessment of temperature sensation may be omitted because both sensations are transmitted by the same ascending pathways
A patient’s eyes jerk while the patient looks to the left. You will record this finding as?
A. Nystagmus
B. CN VI palsy
C. Oculocephalia
D. Ophthalmic dyskenesia
A. Nystagmus
Rationale: Nystagmus is defined as fine, rapid jerking movements of the eyes.
The nurse is caring for a patient with peripheral neuropathy who is going to have EMG studies tomorrow morning. The nurse should?
A. Ensure the patient has an empty bladder
B. Instruct the patient that there is no risk of electric shock
C. Ensure the patient has no metallic jewelry or metal fragments
D. Instruct the patient that she or he may experience pain during the study
B. Instruct the patient that there is no risk of electric shock
Rationale: Electromyography (EMG) is used to assess electrical activity associated with nerves and skeletal muscles. Activity is recorded by insertion of needle electrodes to detect muscle and peripheral nerve disease. The nurse should inform the patient that pain and discomfort are associated with insertion of needles. There is no risk of electric shock with this procedure.
When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment?
A. Ataxia
B. Apraxia
C. Anisocoria
D. Anosognosia
A. Ataxia
Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex.
When assessing the accessory nerve, what should the nurse do?
A. Assess the gag reflex by stroking the posterior pharynx.
B. Ask the patient to shrug the shoulders against resistance.
C. Ask the patient to push the tongue to either side against resistance.
D. Have the patient say “ah” while visualizing elevation of soft palate
B. Ask the patient to shrug the shoulders against resistance.
The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying “ah” are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance and to stick out the tongue are used to assess the hypoglossal nerve
When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm demonstrated by downward drifting of the arm. How should the nurse most accurately document this finding?
A. Athetosis
B. Hypotonia
C. Hemiparesis
D. Pronator drift
D. Pronator drift
Downward drifting of the arm or pronation of the palm is identified as a pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body.
A patient’s sudden onset of hemiplegia has necessitated a computed tomography (CT) of her head. Which assessment should the nurse complete prior to this diagnostic study?
A. Assess the patient’s immunization history.
B. Screen the patient for any metal parts or a pacemaker.
C. Assess the patient for allergies to shellfish, iodine, or dyes.
D. Assess the patient’s need for tranquilizers or antiseizure medications.
C. Assess the patient for allergies to shellfish, iodine, or dyes.
Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient’s immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in the majority of patients.
A patient who has a neurologic disease that affects the pyramidal tract is likely to manifest what sign?
A. Impaired muscle movement
B. Decreased deep tendon reflexes
C. Decreased level of consciousness
D. Impaired sensation of touch, pain, and temperature
A. Impaired muscle movement
Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement because of hypertonicity. Diseases affecting the pyramidal tract do not result in changes in LOC, impaired reflexes, or decreased sensation.
How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury?
A. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together.
B. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance.
C. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm.
D. Place the two points of a calibrated compass on the tips of the fingers and toes and ask the patient to discriminate the points.
B. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance.
The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. The other cited tests of neurologic function do not directly assess position sense.
The new patient has a diagnosis of frontal lobe dementia. What functional difficulties should the nurse expect in this patient?
A. The lack of reflexes
B. Endocrine problems
C. Higher cognitive function abnormalities
D. Respiratory, vasomotor, and cardiac dysfunction
C. Higher cognitive function abnormalities
Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there were a problem in the medulla.
Which normal nervous system changes of aging put the geriatric person at higher risk of falls (select all that apply)?
A. Memory deficit B. Sensory deficit C. Motor function deficit D. Cranial and spinal nerves E. Reticular activation system F. Central nervous system changes
B. Sensory deficit
C. Motor function deficit
F. Central nervous system changes
An older person is at a higher risk for falls because the changes in the nervous system decrease the sensory function that leads to poor ability to maintain balance and a widened gait. The motor function deficit decreases muscle strength and agility. The central nervous system changes in the brain lead to a diminished kinesthetic sense or position sense. Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation system do not contribute to the increased risk of falls.
A patient is having a transsphenoidal hypophysectomy. The nurse should provide preoperative patient teaching about what potential deficit as a result of the surgery?
A. Increased heart rate
B. Loss of coordination
C. Impaired swallowing
D. Altered sense of smell
D. Altered sense of smell
Using a transsphenoidal approach to remove the pituitary gland includes a risk of damage to the olfactory cranial nerve because the cell bodies of the olfactory nerve are located in the nasal epithelium. With damage to this nerve, the sense of smell would be altered. Increased heart rate, loss of coordination, and impaired swallowing will not be potential deficits from this surgery.
The nurse is preparing the patient for an electromyography (EMG). What should the nurse include in teaching the patient before the test?
A.The patient will be tilted on a table during the test.
B. It is noninvasive, and there is no risk of electric shock.
C.The pain that occurs is from the insertion of the needles.
D.The passive sensor does not make contact with the patient.
C.The pain that occurs is from the insertion of the needles.
With an EMG, pain may occur when needles are inserted to record the electrical activity of nerve and skeletal muscle. The patient is tilted on a table during a myelogram. The electroencephalography (EEG) is noninvasive without a danger of electric shock. The magnetoencephalography (MEG) is done with a passive sensor that does not make contact with the patient.
A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia?
a. The patient was oriented and alert when admitted.
b. The patient’s speech is fragmented and incoherent.
c. The patient is oriented to person but disoriented to place and time.
d. The patient has a history of increasing confusion over several years
a. The patient was oriented and alert when admitted.
The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.
DIF: Cognitive Level: Understand (comprehension) REF: 1459 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago?
a. Provide complete personal hygiene care for the patient.
b. Remind the patient frequently about being in the hospital.
c. Reposition the patient frequently to avoid skin breakdown.
d. Place suction at the bedside to decrease the risk for aspiration.
b. Remind the patient frequently about being in the hospital.
The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.
DIF: Cognitive Level: Apply (application) REF: 1453 TOP: Nursing Process: Planning MSC: NCLEX: Physiological
When administering a mental status examination to a patient with delirium, the nurse should
a. wait until the patient is well-rested.
b. administer an anxiolytic medication.
c. choose a place without distracting stimuli.
d. reorient the patient during the examination.
c. choose a place without distracting stimuli.
Because overstimulation by environmental factors can distract the patient from the task of answering the nurse’s questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient’s delirium.
The nurse is concerned about a postoperative patient’s risk for injury during an episode of delirium. The most appropriate action by the nurse is to
a. secure the patient in bed using a soft chest restraint.
b. ask the health care provider to order an antipsychotic drug.
c. instruct family members to remain with the patient and prevent injury.
d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.
d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.
The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patient’s safety. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have many side effects. Restraints are not recommended because they can increase the patient’s agitation and disorientation.
DIF: Cognitive Level: Apply (application) REF: 1460 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environme
