neclex+ati

Question 1

meningeal irritation

Answer 1

stiffness and soreness in the neck area

Question 2

is observed if the supine client passively flexes the hip and knee in response to neck flexion by the examiner, and the client reports pain in the vertebral column.

Answer 2

A positive Brudzinski’s sign

Question 3

also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended.

Answer 3

Kernig’s sign

Question 4

is abnormal flexion and is noted when the client’s upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

This posturing occurs with severe brain damage, and the client requires emergency medical attention.

Answer 4

** Decorticate** posturing

Question 5

Semi-Fowler’s position
With the foot of the bed flat
The head is in a neutral, midline position.

For how long? Can they walk?

Answer 5

craniotomy

Question 6

increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities may also arise.

Answer 6

increased intracranial pressure (ICP)

Question 7

Separates into concentric rings and tests positive for glucose

Answer 7

cerebrospinal fluid (CSF)

Question 8

confusion, difficulty awakening or speaking, one-sided weakness, vomiting, or severe headache. Minor headache is expected.

Answer 8

return to the ED after consussion

Question 9

is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage

Answer 9

A concussion after head injury

Question 10

Comparing the amount of prescribed weights with the amount in use

Answer 10

Crutchfield tongs

Question 11

are applied after drilling holes in the client’s skull under local anesthesia.

Answer 11

Crutchfield tongs

Question 12

The client should not drive because the device impairs the range of vision.
The halo device alters balance and can cause fatigue because of its weight.

Answer 12

halo device

Question 13

spinal cord injury
+
severe, throbbing headache
flushing of the face and neck bradycardia
sudden severe hypertension
nasal stuffiness
blurred vision
nausea
sweating

Answer 13

autonomic dysreflexia

It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

Question 14

Key nursing actions are to sit the client up in bed, remove the noxious stimulus, and bring the blood pressure under control with antihypertensive medication per protocol.

Answer 14

autonomic dysreflexia

Question 15

gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions

Answer 15

cholinergic crisis

Question 16

Side and adverse effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors.

Answer 16

meperidine hydrochloride

Question 17

myasthenia gravis
+
An injection of edrophonium is administered
–>

Answer 17

A temporary worsening of the condition - negative test –> experiencing cholinergic crisis

An improvement of the weakness - positive tests –> myasthenia gravis

Question 18

trigeminal neuralgia
+
carbamazepine

Answer 18

blood dyscrasia

Question 19

stroke + **aphasic **

Question 20

aphasia

Answer 20

loss or impairment of the power to use or comprehend words usually resulting from brain damage (as from a stroke, head injury, or infection)

Question 21

immune system begins to attact the body system - destroy the myelin sheeth that surronds the axons of many nerve cells, and sometimes, the axons themselves

Answer 21

Guillain-Bar`ré syndrome

Question 22

multiple sclerosis

Answer 22

Multiple sclerosis (MS) damages the protective cover around nerves called myelin in your central nervous system.
It can cause muscle weakness, vision changes, numbness and memory issues. While there isn’t a cure, treatment options can help you manage symptoms and slow disease progression.

Question 23

methocarbamol

Answer 23

Intravenous administration of methocarbamol can cause hypotension and** bradycardia **.

Question 24

Bruising behind ears (“Battle’s sign”)

Bruising around eyes (“raccoon eyes”)

Bloody or clear drainage from the auditory canal

Answer 24

a basal skull fracture

Question 25

cerebellar lesion

Answer 25

Rationale:
The cerebellum is responsible for balance and coordination.

waker

Question 26

premolded splint

Answer 26

Question 27

Skin breakdown
Diminished peripheral perfusion

Answer 27

hypothermia blanket

Question 28

thermoregulatory center

Answer 28

Hypothalamus

Question 29

It is the opioid analgesic often used for clients after craniotomy.

It is frequently combined with a nonopioid analgesic such as acetaminophen for added effect.

It does not alter the respiratory rate or mask neuological signs as do other opioids.

Answer 29

codeine sulfate

Question 30

is the altered physiologic state immediately after a spinal cord injury (SCI),
which presents as loss of spinal cord function caudal to the level of the injury, with flaccid paralysis, anesthesia, absent bowel and bladder control, and loss of reflex activity.

Answer 30

Spinal shock

Question 31

seizure assessment

Answer 31

Typically, seizure assessment includes
the time the seizure began,

part(s) of the body affected,

the type of movements and progression of the seizure,

**changes in pupil size, eye deviation or nystagmus, **

client condition and vital signs during the seizure, and postictal status.

Question 32

The client should avoid activities that could worsen the symptoms, including
stress,
infection,
heat (including saunas, staying out of the sun at the beach),
surgery,
or alcohol.

Answer 32

myasthenia gravis