Multiple Choice
Identify the
choice that best completes the statement or answers the question.
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1.
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A nurse explains that the spinal cord extends from
the brainstem to the level of which vertebra?
a. | Last thoracic | b. | Second lumbar | c. | First
sacral | d. | Coccygeal |
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2.
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On admission to the emergency department, a patient
with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities.
The distraught family asks if the paralysis is permanent. What is the best response by the
nurse?
a. | “Yes. In all likelihood, the paralysis is probably
permanent.” | b. | “No.
Significant recovery of function should occur in a few days.” | c. | “It is too early to tell. When the spinal shock subsides, we will know
more.” | d. | “You should
talk to your physician about things of that nature.” |
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3.
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Which assessment would indicate the resolution of
spinal shock?
a. | Extension and rigidity in affected
limbs | b. | Spastic involuntary movements in affected
limbs | c. | Tingling and burning in affected
limbs | d. | Voluntary purposeful movements of affected
limbs |
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4.
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Which assessment leads the emergency department
nurse to suspect that a patient’s spinal cord injury (SCI) is below C4?
a. | Voluntary eye movement | b. | Ability to blink the eyelids | c. | Unlabored respiration | d. | Ability to make a
facial grimace |
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5.
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During a neurologic assessment, a nurse asks a
patient to dorsiflex the foot against the resistance of the nurse’s hand. The patient is unable
to perform this action. Where does this assessment confirm that cord damage has
occurred?
a. | C4 to C5 | b. | L2 to L4 | c. | L5 | d. | S1 |
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6.
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What technique should the nurse implement to move
the impaired legs of a patient with an SCI to avoid stimulation muscle spasm?
a. | Firmly grasping the calf muscle and the thigh
muscle | b. | Manipulating the limb by supporting the knee and ankle
joints | c. | Holding the foot upright and slowly dragging the limb
into position | d. | Requesting
assistance to support the calf and thigh |
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7.
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When recording the findings of muscle strength, a
nurse records a 2 for the right arm. How should his score be interpreted?
a. | Weak contraction | b. | Muscle movement when supported | c. | Active muscle movement without support | d. | Full, active range-of-motion exercises against
resistance |
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8.
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Which technique of opening the airway in the newly
admitted patient with an SCI is the most appropriate?
a. | Chin lift | b. | Head tilt | c. | Jaw
thrust | d. | Neck flexion |
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9.
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Brown-Séquard syndrome results in which
neurologic deficit?
a. | Bilateral loss of pain sensation below the level of
injury | b. | Bilateral loss of temperature and motor function below
the level of injury | c. | Motor and sensory
loss in the upper extremities only | d. | Ipsilateral loss
of motor function and contralateral loss of pain sensation and
temperature |
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10.
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Which level of independence is an appropriate
nursing care plan goal for a patient with a C8 transection?
a. | Manage a mechanical wheelchair with a
joystick. | b. | Manage a mechanical wheelchair with hand
control. | c. | Manage a specially equipped
wheelchair. | d. | Manage an ordinary
wheelchair. |
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11.
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A paraplegic patient excitedly reports seeing his
foot move when he was being turned. How is this phenomenon best explained?
a. | Reflexive movement | b. | Return of motor function | c. | Early symptom of
autonomic dysreflexia | d. | Result of
hypertonicity of the muscle |
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12.
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After spinal shock has been resolved, an indwelling
catheter is removed. What way should the nurse expect this patient to empty the
bladder?
a. | Manual expression (Credé
method) | b. | Spontaneous reflexive action | c. | Normal voluntary control | d. | Self-catheterization |
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13.
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A distressed family member asks about the purpose
of the Gardner-Wells tongs. Which is the most helpful explanation by the nurse regarding the action
of Gardner-Wells tongs?
a. | Compress the cervical
vertebrae. | b. | Immobilize the
head. | c. | Allow the patient to be moved out of
bed. | d. | Align the cervical
vertebrae. |
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14.
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What is the major advantage of the halo device over
the Gardner-Wells tongs?
a. | Separates the cervical
vertebrae | b. | Allows the patient out of bed | c. | Aligns the cervical spine | d. | Relieves pain |
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15.
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A patient is receiving methylprednisolone. What
purpose should the nurse explain this drug has in treating a patient with an SCI?
a. | Reduces spinal cord cellular
damage | b. | Counteracts spinal shock | c. | Increases blood supply to the injured cord | d. | Enhances sexual function |
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16.
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A patient with an SCI begins to have seizures, and
the blood pressure (BP) rises rapidly to 210/160 mm Hg. Which is the third indicator of the syndrome
of autonomic dysreflexia?
a. | Profuse vomiting | b. | Hives on face and neck | c. | Excessive urine
output | d. | Bradycardia |
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17.
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What should be the immediate intervention when a
nurse recognizes autonomic dysreflexia in the patient with an SCI?
a. | Flex the patient’s legs using the knee gatch of
the bed. | b. | Cool the patient with alcohol
solution. | c. | Raise the head of the bed to at least 45
degrees. | d. | Administer oxygen per
mask. |
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18.
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Which intervention by a nurse is effective in the
prevention of autonomic dysreflexia in the patient with an SCI?
a. | Ensure patency of the urinary
catheter. | b. | Give warm baths to the patient to stimulate
vasodilation. | c. | Keep lighting at a
minimum to reduce stimulation. | d. | Offer the patient
four or five small meals daily. |
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19.
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A nurse tells a patient with quadriplegia that he
is being treated with intravenous (IV) drugs because this method is more effective than
intramuscularly (IM). What explanation should the nurse provide about IM medications to explain to
the patient why they are less effective than IV?
a. | Too concentrated | b. | Too irritating to poorly perfused tissue | c. | Not absorbed well below the level of the injury | d. | Too small a dose to be effective |
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20.
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The family members of a patient with an SCI, who is
in the rehabilitation phase, wants to take the patient outdoors for a visit. It is 90° F outside
and very humid. What should the nurse suggest?
a. | Do not go outside at all but remain in the
hospital. | b. | Take a spray bottle to spray water to cool the patient
by evaporation. | c. | Take a light
sweater to insulate the patient. | d. | Have the patient
drink at least 32 oz of water during the outing. |
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21.
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A nurse notes that no urinary output has occurred
in a patient who underwent a laminectomy 2 hours earlier. What action should the nurse
implement?
a. | Continue to monitor. | b. | Inform the charge nurse. | c. | Perform
intermittent catheterizations. | d. | Turn the patient
to the right side. |
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22.
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Which statement made by a male patient with an SCI
could be assessed as a positive adaptation to the nursing diagnosis of “Sexual dysfunction,
related to altered body function”?
a. | “I know I will never have a sexual relationship
again.” | b. | “I need some
suggestions as to how to direct my sexual energy into gardening or painting . . . or just
anything.” | c. | “Can you
arrange an appointment with a sex counselor so I can begin to examine alternative methods of sexual
activity?” | d. | “I think
that after a while I will be able to have sexual relationships just like I had before my
accident.” |
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23.
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What should a nurse emphasize regarding the
rehabilitation of the patient with an SCI?
a. | Rehabilitation is usually achieved within a few months
after stabilization. | b. | Rehabilitation
will return the patient with an SCI to the preaccident functional level. | c. | Rehabilitation focuses on adjustments necessary to reenter society and the
workplace. | d. | Rehabilitation
completely targets self-care. |
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24.
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What should a nurse include in a patient’s
plan of care when considering interventions for the outcome of prevention of contractures in a
patient with an SCI?
a. | Apply cold wraps to the limbs twice a
day. | b. | Perform full ROM exercises every 2
hours. | c. | Use significant tactile stimuli each
shift. | d. | Apply splints to the
limbs. |
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25.
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The family of a patient with an SCI is concerned
with the lack of bowel function 2 days after the injury. What is the best response by the
nurse?
a. | “Because of his injury, he will always need to
have enemas for bowel evacuation.” | b. | “Medical
management is delaying bowel action because it places pressure on the
injury.” | c. | “Bowel
function should return in approximately 3 days after the accident.” | d. | “We’ll just have to wait and see if bowel action returns this
week.” |
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26.
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What should a nurse explain when a patient with an
SCI inquires what the physician means by a cone-down?
a. | A cone is surgically placed over the spine to protect
the cord. | b. | Marks will be placed on either side of the injury to
mark the area. | c. | A cone-shaped
wedge of bone will be placed between the vertebrae. | d. | A detailed radiographic image will be taken of the spinal
injury. |
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27.
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What should a nurse encourage a patient with an SCI
to do after a computed tomography (CT) scan?
a. | Sit up at a 30-degree angle. | b. | Prevent chilling. | c. | Drink plenty of
water. | d. | Avoid bearing
down. |
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28.
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What are the two divisions of the nervous
system?
a. | Somatic and the autonomic | b. | Cerebellum and the brainstem | c. | Medulla oblongata and the diencephalon | d. | Central and the peripheral |
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29.
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What is the cranial nerve that supplies most of the
organs in the thoracic and abdominal cavities and also carries motor fibers to glands that produce
digestive juices and other secretions?
a. | Somatic motor nerve | b. | Visceral sensory nerve | c. | Abducens
nerve | d. | Vagus nerve |
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30.
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The newly admitted patient to the emergency room 30
minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly
reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible.
What is the most appropriate position for the patient?
a. | Neck placed in a neutral
position | b. | Head raised slightly with hips
flexed | c. | Supine in gravity neutral
position | d. | Turn on right side with head
elevated |
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31.
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Which question is likely to elicit the most valid
response from the patient who is being interviewed about a neurologic problem?
a. | “Do you have any sensations of pins and needles in
your feet?” | b. | “Does the
pain radiate from your back into your legs?” | c. | “Can you describe the sensations you are
having?” | d. | “Do you ever
have any nausea or dizziness?” |
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32.
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What is the cardinal sign of increased intracranial
pressure in a brain injured patient?
a. | Pupil changes | b. | Ipsilateral paralysis | c. | Vomiting | d. | Decrease in the
level of consciousness |
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33.
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The nurse is aware that when assessing a patient by
the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem
reflexes, motor response, and respiration. How are these results reported?
a. | As a sum of the scores of the four
categories | b. | As part of the
Glasgow coma scale | c. | As individual
scores in each category | d. | As progressive
scores during a 24-hour period |
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34.
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As the result of a stroke, a patient has difficulty
discerning the position of his body without looking at it. In the nurse’s documentation, which
would best describe the patient’s inability to assess spatial position of his
body?
a. | Agnosia | b. | Proprioception | c. | Apraxia | d. | Sensation |
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35.
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A patient, age 45, is to have a myelogram to
confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with
respect to this diagnostic test?
a. | Obtain an allergy history before the
test. | b. | Ambulate the patient when returned to the room after the
test. | c. | Use heated blanket to keep patient warm after
procedure. | d. | Keep NPO for 6 to
8 hours after the test. |
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36.
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A patient has recently suffered a stroke with
left-sided weakness and has problems with choking, especially when drinking thin liquids. What
nursing interventions would be most helpful in assisting this patient to swallow
safely?
a. | Use a straw | b. | Tuck chin when swallowing | c. | Take a sip of liquid with each bite | d. | Turn head to the left |
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37.
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What are surgical navigational
systems?
a. | Computerized devices that guide the
surgeon | b. | A set of detailed anatomic maps pinpointing specific
areas of the brain | c. | A written set of
progressive processes for the resection of small brain tumors | d. | The use of radioactive materials to pinpoint small tumors of the
brain |
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38.
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A family member of a patient who has just suffered
a tonic-clonic seizure is concerned about the patient’s deep sleep. What is this behavior
called?
a. | Convalescent period | b. | Neural recovery period | c. | Sombulant
period | d. | Postictal period |
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39.
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How would a nurse record the behavior when a
patient with Alzheimer disease attempts to eat using a napkin rather than a fork?
a. | Apraxia | b. | Agnosia | c. | Aphasia | d. | Dysphagia |
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40.
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Which symptom is specific to migraine
headaches?
a. | Tachycardia | b. | They become worse in the evening | c. | They involve the entire head | d. | They are preceded by an aura |
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41.
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The nurse assures an anxious family member of a
92-year-old patient who is demonstrating signs of dementia that many causes of dementia are
reversible and preventable. What is one example?
a. | Hypotension | b. | Alzheimer disease | c. | Diabetes | d. | Parkinson
disease |
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42.
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What is the nurse assessing when asking the
patient, “Who is the president of the United States?” during a level of consciousness
assessment?
a. | Orientation | b. | Memory | c. | Calculation | d. | Fund of
knowledge |
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43.
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What Glasgow Coma Scale rating would a patient
receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for
movement?
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44.
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What is the nurse aware of when assessing a person
with a craniocerebral injury?
a. | Most injuries of this type are
irreversible | b. | Open injuries are
always more serious than closed injuries | c. | Signs and symptoms
may not occur until several days after the trauma | d. | Trauma to the frontal lobe is more significant than to any other
area |
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45.
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The nurse is caring for a home health patient who
had a spinal cord injury at C5 three years ago. The nurse bases the plan of care on the knowledge
that the patient will be able to:
a. | feed self with setup and adaptive
equipment. | b. | transfer self to
wheelchair. | c. | stand erect with
full leg braces. | d. | sit with good
balance. |
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46.
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A frantic family member is distressed about the
flaccid paralysis of her son following a spinal cord injury several hours ago. What does the nurse
know about this condition?
a. | It is an ominous indicator of permanent
paralysis. | b. | It is possibly a
temporary condition and will clear. | c. | It degenerates
into a spastic paralysis. | d. | It will progress
up the cord to cause seizures. |
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47.
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A patient with a spinal cord injury at T1 complains
of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and “goose
flesh.” What should be the primary nursing intervention based on these
assessments?
a. | Place patient in flat position and check
temperature | b. | Administer oxygen
and check oxygen saturation | c. | Place on side and
check for leg swelling | d. | Sit upright and
check blood pressure |
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48.
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The nurse is aware that the characteristic gait of
the person with Parkinson disease is a propulsive gait, which causes the patient to:
a. | stagger and need support of a
walker. | b. | shuffle with arms flexed. | c. | fall over to one wide when walking. | d. | take small steps balanced on the toes. |
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49.
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What does the nurse know about the stroke patient
who has expressive aphasia?
a. | Has difficulty comprehending spoken and written
communication | b. | Cannot make any
vocal sounds | c. | Has total loss and
comprehension of language | d. | Can understand the
spoken word, but cannot speak |
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50.
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The nurse is aware that the drug t-PA (Activase), a
tissue plasminogen activator, must be given in____hours of the onset of symptoms to have maximum
benefit.
a. | 3 hours | b. | 4 hours | c. | 6
hours | d. | 8 hours |
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51.
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An 83-year-old patient has had a stroke. He is
right-handed and has a history of hypertension and “little” strokes. He presents with
right hemiplegia. To afford him the best visual field, the nurse should approach him:
a. | from the right side. | b. | from the left side. | c. | from the
center. | d. | from either side. |
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52.
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The newly admitted patient to the emergency room
after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most
appropriate nursing response to this assessment?
a. | Cleanse nose with a soft cotton-tipped
swab | b. | Gently suction the nasal
cavity | c. | Gently wipe nose with absorbent
gauze | d. | Ask patient to blow his
nose |
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53.
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How would the nurse instruct a patient with
Parkinson disease to improve activity level?
a. | To use a soft mattress to relax the
spine | b. | To walk with a shuffling gait to avoid
tripping | c. | To walk with hands clasped behind back to help
balance | d. | To sit in hard chair with arms for posture
control |
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54.
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What is the basic problem that prompts most of the
early signs of Alzheimer disease?
a. | Changes in mood | b. | Misplacing things | c. | Memory loss that
disrupts daily life | d. | Problems with
words in speaking |
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55.
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A patient is in which stage of Alzheimer disease
when she demonstrates “sundowning”?
a. | Early stage | b. | Second stage | c. | Third
stage | d. | Final stage |
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56.
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Why are the drugs neostigmine (Prostigmin) and
pyridostigmine (Mestinon) helpful to the person with myasthenia gravis?
a. | Improves speech | b. | Improves visual disturbances | c. | Reduces pain | d. | Promotes nerve
impulse transmission |
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57.
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What should the nurse do when the child arrives on
the floor with the diagnosis of bacterial meningitis?
a. | Arrange for humidified oxygen per
mask | b. | Place the child in respiratory
isolation | c. | Inquire about drug allergy | d. | Hold NPO until orders arrive |
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58.
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What is the purpose of a “drug holiday”
in the treatment of Parkinson disease?
a. | Change all drugs | b. | Allow the natural dopamine levels to rise | c. | Restart drugs at a lower dosage with favorable
results | d. | Reduce the extrapyramidal
symptoms |
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59.
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What is the first sign of Bell’s
palsy?
a. | Inability to wrinkle forehead and pucker lips on
affected side | b. | Sudden pain in
nostril on affected side | c. | Excessive
salivation on the affected side | d. | Excessive mucus
running from nostril on affected side |
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60.
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Following a myelogram the nurse should include in
the postprocedure care assessment for:
a. | elevation of blood pressure. | b. | urine retention. | c. | sensation in lower
extremities. | d. | slurred
speech. |
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61.
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Why is the patient with suspected Guillain-Barre
Syndrome (GBS) hospitalized immediately?
a. | The infection needs to be treated with IV antibiotics to
prevent paralysis | b. | The brain may
swell quickly causing seizures | c. | The disease can
rapidly progress into respiratory failure | d. | IV hydration is
needed to prevent possible fatal hypotension |
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62.
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To what does the neural synapse
refer?
a. | Length of time it takes for afferent neurons to carry
impulses to the central nervous system (CNS) | b. | Length of time it
takes for efferent neurons to carry impulses to the motor neurons | c. | Space between the axons and the dendrites of a
neuron | d. | Space between the axons of one neuron and the dendrites
of the next |
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63.
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An older adult patient is experiencing extreme
stress related to an admission to the hospital. What should the nurse expect the patient to
demonstrate?
a. | Decreased heart rate | b. | Decreased blood pressure (BP) | c. | Irregular respiration | d. | Dilation of the
pupils |
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64.
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Which neurologic finding would be considered
abnormal in an 88-year-old patient?
a. | Slow papillary response to
light | b. | Jerky eye movements | c. | Dizziness and problems with balance | d. | Absence of the Achilles tendon jerk |
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65.
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What is the most reliable indicator of neurologic
status?
a. | Blood pressure | b. | Pulse rate | c. | Temperature | d. | Level of
consciousness |
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66.
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A patient is stuporous but reacts by withdrawing
from painful stimuli. What term is most appropriate for this patient?
a. | Comatose | b. | Lethargic | c. | Semicomatose | d. | Somnolent |
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67.
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Which describes the Babinski reflex?
a. | Downward curl of the toes | b. | Big toe bending upward | c. | Spreading out of
the toes | d. | Pain in the big
toe |
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68.
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What should the nurse assess for the when a patient
is scheduled for an angiogram?
a. | Dizziness | b. | Allergy to shrimp | c. | Increased
BP | d. | Irregular
heartbeat |
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69.
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What diagnostic test might be contraindicate for a
patient who has a pacemaker?
a. | Computed tomography (CT) | b. | Electromyography (EMG) | c. | Magnetic resonance
imaging (MRI) | d. | Electroencephalography (EEG) |
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70.
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A patient with a severe head injury begins to
assume a posture of flexed upper extremities, with plantarflexed lower extremities. What do these
assessments indicate?
a. | Increasing intracranial pressure (ICP) with decorticate
posturing | b. | Decreasing ICP with decerebrate
posturing | c. | Decreasing ICP with decorticate
posturing | d. | Increasing ICP with decerebrate
posturing |
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71.
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What should be immediately reported by the nurse
caring for a 90-year-old patient with a closed head injury?
a. | Blood pressure change from 147/72 to 176/70 mm
Hg | b. | Respiration rate increase from 14 to 18
breaths/min | c. | Slow pupillary
reaction bilaterally | d. | Temperature
decrease from 100.2° F to 97.6° F |
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72.
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A patient with generalized convulsive disorder has
a nursing diagnosis of “Deficient knowledge, related to lack of information about the side
effects of phenytoin (Dilantin).” Which goal and outcome criteria would be most
appropriate?
a. | Absence of gastrointestinal (GI) complaint; takes
medication with food | b. | Stimulation of
gingiva; brushes teeth vigorously to encourage gingival growth | c. | Maintenance of normal pattern of elimination; limits fluids and eats foods
that reduce diarrhea | d. | Maintenance of
normal sleep pattern; reduces stimuli and takes warm baths to induce
drowsiness |
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73.
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A nurse is caring for a patient with meningitis who
has a positive Brudzinski sign. Which assessment led to this conclusion?
a. | Flexed hips when the neck is flexed by the
nurse | b. | Inability to extend the flexed leg fully because of
hamstring pain | c. | Resisting efforts
of the nurse to flex his or her neck | d. | Flexing the big
toe upward and fan out the other toes |
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74.
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Which assessment on a patient on mannitol therapy
for cerebral edema indicates the medication is effective in decreasing ICP?
a. | Increased BP | b. | Increased urinary output | c. | Decreased
pulse | d. | Widening pulse
pressure |
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75.
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What should a nurse instruct a patient after a
lumbar puncture to prevent a headache?
a. | Lie flat. | b. | Lie on left side. | c. | Stay in
semi-Fowler position. | d. | Ambulate in the
room with assistance. |
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76.
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Which three symptoms are characteristic of Cushing
triad associated with increased ICP?
a. | Hypotension, tachycardia, and narrowing pulse
pressure | b. | Hypertension, tachycardia, and
headache | c. | Widening pulse pressure, headache, and
seizure | d. | Bradycardia, hypertension, and widening pulse
pressure |
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77.
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A nurse is evaluating the goal of teaching for the
nursing diagnosis of “Knowledge deficit, related to conservation of energy in a patient with
multiple sclerosis” (MS). Which statement by the patient indicates a positive
outcome?
a. | “Now that I am taking steroids, I will be able to
work like I used to.” | b. | “I’m
making a list of things that are important and things I will simply have to let
go.” | c. | “I will make
a plan to allow for long rest periods at least four times a day.” | d. | “I am working on balancing time among rest, work, and family
time.” |
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78.
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A patient in the emergency department states that
she fell and hit her head and blacked out for a while but became alert again. The nurse suspects an
epidural hematoma. For what should the nurse be diligent to assess?
a. | Headache | b. | Drowsiness | c. | Increasing
respiration rate | d. | Vomiting |
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79.
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Which intervention should be added to the nursing
care plan for supporting nutritional intake in a patient with Parkinson disease?
a. | Offer large meals with a variety of finger
foods. | b. | Thicken liquids to make them easier to
swallow. | c. | Puree all foods and drink through a
straw. | d. | Offer a diet high in carbohydrates and fat and low in
protein. |
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80.
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A patient with Parkinson disease is depressed
because his drug protocol of L-dopa and Sinemet is no longer controlling his symptoms. What is the
best response by the nurse?
a. | Other drugs can be combined with L-dopa to increase its effectiveness. | b. | The effect of these drugs has an uneven course; symptoms will begin to subside
again soon. | c. | The two drugs can
be given in higher doses to control the symptoms. | d. | Surgical interventions have been very effective in the control of parkinsonian
symptoms. |
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81.
|
A patient with Parkinson disease is considering
taking St. John’s wort, an herbal remedy for depression, in addition to Sinemet and
L-dopa. What is the most appropriate nursing
response?
a. | Depression is reduced by the use of herbal remedies such
as St. John’s wort. | b. | Doses of St.
John’s wort and parkinsonian drugs should be taken on alternate
days. | c. | St. John’s wort must be taken in large doses to
reduce depression. | d. | Herbal remedies
can interfere with the effectiveness of the parkinsonian
drugs. |
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82.
|
Which nursing assessment would indicate a need for
suctioning a patient with Guillain-Barré who is experiencing impaired breathing patterns because
of neuromuscular failure?
a. | Decreased pulse rate and respiration of 20
breaths/min | b. | Increased pulse
rate and adventitious breath sounds | c. | Increased pulse
rate and respiration of 16 breaths/min | d. | Decreased pulse
and abdominal breathing |
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83.
|
A family member asks the nurse what would be an
appropriate gift for a patient with Parkinson disease. What is the most useful
suggestion?
a. | Soft-soled house shoes | b. | Jigsaw puzzle | c. | Set of card
games | d. | Satin sheets |
|
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84.
|
What action should the nurse implement when a
patient falls to the floor in a generalized seizure?
a. | Cradle the head to prevent
injury. | b. | Insert an object between the teeth to prevent the
patient from biting the tongue. | c. | Manually restrain
the limbs. | d. | Keep the patient
on his or her back to prevent aspiration. |
|
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85.
|
How can the nurse help reduce ICP in caring for the
patient after a craniotomy?
a. | Keeping the patient flat in
bed | b. | Elevating the head of the bed 30
degrees | c. | Closely monitoring the IV
rate | d. | Turning the patient to the right
side |
|
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86.
|
Why is a patient with amyotrophic lateral sclerosis
(ALS) uniquely prone to depression?
a. | Nutritional intake is poor. | b. | Intellectual capacity is not affected. | c. | Mobility is limited. | d. | Communication is
altered. |
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87.
|
A nurse is careful about limb position in caring
for an unconscious patient who sustained a head injury 10 days ago. What is the nurse trying to
prevent?
a. | Flexion deformities | b. | Atrophy | c. | Paralysis | d. | Pathologic
fracture |
|
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88.
|
What should the nurse implement before giving an
enteral feeding to a patient?
a. | Palpate the abdomen to check for residual
feeding. | b. | Warm the feeding. | c. | Elevate the head of the bed 30 degrees. | d. | Ask the patient to tip his head
forward. |
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|
89.
|
A patient has weakness on the right side and
impaired reasoning after having a cerebrovascular accident (CVA). What part of the brain is
affected?
a. | Left hemisphere of the
cerebrum | b. | Right hemisphere of the
cerebrum | c. | Left cerebellum | d. | Right cerebellum |
|
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|
90.
|
Which patient is at the greatest risk for a
CVA?
a. | A 20-year-old obese Latin woman who is taking birth
control pills | b. | A 40-year-old
athletic white man with a family history of CVA | c. | A 60-year-old
Asian woman who smokes occasionally | d. | A 65-year-old
African American man with hypertension |
|
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91.
|
A patient experienced a period of momentary
confusion, dizziness, and slurred speech but recovered in 2 hours. Which assessment in the diagnosis
of this episode would be most helpful?
a. | Patient’s complaint of
nausea | b. | Blood pressure (BP) of 140/90 mm
Hg | c. | Patient’s complaint of
headache | d. | Auscultation of a bruit over the carotid
artery |
|
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92.
|
A nurse is updating a teaching plan for a patient
who sustained a TIA. What should the nurse be sure to include?
a. | Daily aspirin dose | b. | Long rest periods daily | c. | Reduction of fluid
intake to 800 mL/day | d. | High-carbohydrate
diet |
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93.
|
A patient recovering from a CVA asks the purpose of
the warfarin (Coumadin). What is the best response by the nurse regarding the purpose of
Coumadin?
a. | Dissolves the clot. | b. | Prevents the formation of new clots. | c. | Dilates the vessels to improve blood flow. | d. | Suppresses the formation of platelets. |
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94.
|
A patient has had a complete stroke as a result of
a ruptured vessel in the left hemisphere. How should this patient’s CVA be
classified?
a. | Ischemic, embolic | b. | Hemorrhagic, subarachnoid | c. | Hemorrhagic, intracerebral | d. | Ischemic, thrombotic |
|
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|
95.
|
What should a nurse ensure as a priority for a
patient immediately after a CVA?
a. | Preservation of motor
function | b. | Airway maintenance | c. | Adequate hydration | d. | Control of
elimination |
|
|
|
96.
|
When should a nurse recognize that the acute phase
of a CVA has ended?
a. | Forty-eight hours has passed from its
onset. | b. | The patient begins to respond
verbally. | c. | BP drops. | d. | Vital signs and neurologic signs
stabilize. |
|
|
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97.
|
A patient in the acute phase of a CVA who has been
speaking distinctly begins to speak indistinctly and only with great effort but still coherent. What
should this nurse determine when assessing this patient?
a. | Stroke in evolution with
dysarthria | b. | Lacunar stroke
with fluent aphasia | c. | Complete stroke
with global aphasia | d. | Stroke in
evolution with dyspraxia |
|
|
|
98.
|
Several days after a CVA, a patient’s family
asks a nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurse’s
response is based on the knowledge that this drug must be used within how many hours after the onset
of symptoms?
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|
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99.
|
A nurse explains that a lumbar puncture is most
helpful as a diagnostic tool for a new patient who has had a CVA. What would this diagnostic test
help determine regarding the stroke?
a. | It is lacunar. | b. | It is hemorrhagic or embolic. | c. | It is complete or in evolution. | d. | It will result in paralysis. |
|
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100.
|
A patient who has sustained a hemorrhagic stroke is
placed on a protocol of 60 mg of calcium channel blocker (nimodipine) every 4 hours. The
patient’s pulse is 82 beats/min before the administration of the prescribed dose. Which action
should the nurse implement?
a. | Give the full dose as prescribed without further
assessment. | b. | Omit the dose,
recording the pulse rate as the rationale. | c. | Delay the dose
until the pulse is below 60 beats/min. | d. | Give half of the
prescribed dose (30 mg). |
|
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|
101.
|
During the acute CVA phase, a risk for falls
related to paralysis is present. Which intervention best protects the patient from
injury?
a. | Keep the bed in a high position for ease of nursing
care. | b. | Keep the side rails up, according to agency
policy. | c. | Assess vision deficit related to
ptosis. | d. | Monitor the condition every 2
hours. |
|
|
|
102.
|
Pneumonia is the most frequent cause of death after
a stroke. Which intervention would be contraindicated in the acute care of a patient with a
hemorrhagic CVA?
a. | Thicken liquids to ease swallowing and prevent
aspiration. | b. | Change position
every 30 to 60 minutes. | c. | Maintain adequate
fluid intake, orally or IV. | d. | Encourage forceful
coughing to stimulate deep breathing. |
|
|
|
103.
|
Which assessment indicates a fluid volume excess in
a patient in the acute phase of a CVA?
a. | Decreased BP | b. | Weak pulse | c. | Adventitious
breath sounds | d. | High
urine-specific gravity |
|
|
|
104.
|
Which intervention should the nurse include in a
patient’s plan of care to help preserve joint mobility in the acute phase of a
CVA?
a. | Pull the limbs on the affected side into a functional
position. | b. | Perform aggressive full range-of-motion exercises for
all extremities. | c. | Support affected
points in good functional alignment. | d. | Exercise the limbs
every 8 hours. |
|
|
|
105.
|
A patient in the acute phase of an embolic CVA has
an order for 400 units of heparin per hour IV. The heparin is in a solution of 5000 units/100 mL
normal saline (NS). The nurse should set the electronic IV monitor at how many milliliters per
hour?
|
|
|
106.
|
Which assessment indicates that a patient with a
CVA is in transition to the rehabilitation phase?
a. | BP has been within normal limits for 24
hours. | b. | Patient makes positive statements about his
condition. | c. | No further
neurologic deficits are observed. | d. | Successful
attempts are made at independent function. |
|
|
|
107.
|
A patient with homonymous hemianopsia is in the
rehabilitation phase of a CVA. When arranging this patient’s environment where should the nurse
assure persons approaching and important items are visible and available?
a. | Unaffected side | b. | Affected side | c. | Direct
front | d. | Either side |
|
|
|
108.
|
Which outcome criterion is the most appropriate for
a patient with “Imbalanced nutrition, related to dysphagia, with the goal of adequate
nutrition”?
a. | Offers a variety of food
groups | b. | Eats half of all meals
offered | c. | Maintains body weight of 150 to 155
lb | d. | Eats all meals
independently |
|
|
|
109.
|
Which is the most effective intervention for best
support of regular bowel elimination and the prevention of constipation?
a. | Limit fluid intake from 32 to 50 oz daily to compact the
stool. | b. | Administer small soapsuds enema every other day to
cleanse the bowel. | c. | Give stool
softeners daily, establishing a consistent time to attempt elimination. | d. | Administer a strong laxative on a daily basis to encourage
evacuation. |
|
|
|
110.
|
A patient in the rehabilitation phase after a CVA
accidentally knocks the adapted plate from the table and bursts into tears after failing to feed
himself. What is the best response by the nurse?
a. | “Don’t cry. You’ll be mastering eating
in no time.” | b. | “I
don’t believe crying will help. Let’s try drinking from a special
cup.” | c. | “Bless your
heart! Let me get a new meal and feed you.” | d. | “Learning new skills is hard. Let’s see what may have caused the
trouble.” |
|
|
|
111.
|
Which instruction is most helpful in teaching the
family and patient who is in the rehabilitation phase after a CVA about altered
sensation?
a. | Make frequent assessments for signs of pressure or
injury. | b. | Use the affected side in supporting the patient in
ambulation and transfer to stimulate better sensation. | c. | Apply ice packs to the affected limbs to encourage a return of
sensation. | d. | Apply a heating
pad to the affected limbs to increase circulation. |
|
|
|
112.
|
Which posthospital option should the nurse
encourage a patient to do when recovering from a CVA to provide the most comprehensive
assistance?
a. | Transfer to a rehabilitation
center. | b. | Discharge to home with scheduled visits from home health
care nurses. | c. | Discharge to home
with scheduled visits from a physical therapist. | d. | Discharge to home with scheduled visits from an occupational
therapist. |
|
|
|
113.
|
The wife of a husband who has had a CVA asks why he
is being treated with insulin since he has no history of diabetes. What is the best response by the
nurse as to why hyperglycemia occurs after a stroke?
a. | Brain swelling | b. | Hypertension | c. | Immobility | d. | Stress |
|
Multiple Response
Identify one
or more choices that best complete the statement or answer the question.
|
|
|
114.
|
Which foods should the person who suffers from
migraine headaches avoid? (Select all that apply.)
|
|
|
115.
|
What are the three signs of Cushing response?
(Select all that apply.)
|
|
|
116.
|
Which of the following techniques are necessary for
safely feeding a hemiplegic patient? (Select all that apply.)
|
|
|
117.
|
What is the reticular activating system (RAS)
essential to? (Select all that apply.)
|
|
|
118.
|
What are the effects of normal aging on the nervous
system? (Select all that apply.)
|
|
|
119.
|
Which neurotransmitters support smooth neural
transmission? (Select all that apply.)
|
|
|
120.
|
A nurse caring for an immobilized patient with a
brain tumor stimulates the patient several times a day with range-of-motion exercises and changes his
position every 2 hours to try to prevent a disuse syndrome. What signs and symptoms does disuse
syndrome include? (Select all that apply.)
|
|
|
121.
|
Which are normal brain alterations associated with
age? (Select all that apply.)
|
|
|
122.
|
Which transitory symptoms might occur when a
patient is diagnosed with a TIA? (Select all that apply.)
|
|
|
123.
|
What purposes exist for a stent in the carotid
artery of a person with a TIA? (Select all that apply.)
|
|
|
124.
|
What signs and symptoms characterize expressive
aphasia? (Select all that apply.)
|
|
|
125.
|
How does a lacunar stroke differ from an ischemic
CVA? (Select all that apply.)
|
|
|
126.
|
Which patients with CVAs are considered candidates
for treatment with tPA? (Select all that apply.)
|
|
|
127.
|
Which home modifications will support
rehabilitation for a patient who had a stroke? (Select all that apply.)
|
|
|
128.
|
What causes the 3% of strokes known to occur in
persons younger than 45 years of age? (Select all that apply.)
|
Completion
Complete each
statement.
|
|
|
129.
|
A nurse checks the oxygen in the circulating volume
for adequate concentration to support the brain’s need of _____% of the oxygen supply of the
body.
|
|
|
130.
|
_________________ is/are responsible for the
transmission of impulses between synapses.
|
|
|
131.
|
A ___________ is a diagnostic procedure used to
identify lesions by observing the flow of radiopaque dye through the subarachnoid
space.
|
|
|
132.
|
The nurse explains that the triad of signs of
Parkinson disease is: _______, _______ and _______
|
|
|
133.
|
Involuntary rhythmic movement of the eyes, with
oscillations that may be horizontal, vertical, or mixed movements, is called
___________________
|
|
|
134.
|
The waxy substance that covers the neuron fibers
and increases the rate of transmission of impulses is the ________.
|
Other
|
|
|
135.
|
The nurse assessing the level of consciousness in a
patient will perform the following: (Arrange in order from the simplest to the most complex.
Separate letters by a comma and space as follows: A, B, C, D.)
A. Apply pressure to the nail bed.
B. Shake the
patient.
C. Touch the patient.
D. Call the patient’s
name.
E. Approach the patient.
|
|
|
136.
|
The nurse conducting a Romberg test will ask the
patient to do what? (Arrange in the correct sequence. Separate letters by a comma and space as
follows: A, B, C, D.)
A. Touch his or her nose with the index finger with the eyes
open.
B. Stand with eyes closed.
C. Touch his or her nose with the
index finger with the eyes closed.
D. Touch his or her fingertip to nurse’s
fingertip.
E. Pat the knees with the palms and then the back of the hands
rapidly.
|
|
|
137.
|
The nurse explains that the two divisions of the
autonomic nervous system work to maintain homeostasis. Place in order the autonomic events. (Separate
letters by a comma and space as follows: A, B, C, D)
a. Parasympathetic nervous system
dominates
b. Extremely stressful or frightening event
c. Blood pressure, heart rate, and
adrenaline output decrease
d. Sympathetic nervous system dominates
e. Heart rate and blood
pressure rise, secretion of adrenaline
|