Exam 1

Question 1

What are the levels of consciousness

Answer 1

Alert
Lethargic
Obtunded
Semi comatose
Comatose

Question 2

Alert

Answer 2

Receptive and responsive

Question 3

Lethargic

Answer 3

Responds appropriately but is slow and may need stimuli to remain awake

Question 4

Obtunded

Answer 4

Difficult to arouse, requires constant stimulation to stay awake and inconsistently follows commands

Question 5

Semicomatose

Answer 5

Requires extreme or repeated stimuli but responds with purposeful movement, does not follow commands, nonverbal

Question 6

Comatose

Answer 6

Unconscious with no meaning response to stimuli

Question 7

PERRLA

Answer 7

Pupils equal round react to light and accommodate- coverage and constrict

Question 8

Miosis

Answer 8

<3mm

Question 9

Mydriasis

Answer 9

> 7mm

Question 10

Anisocoria

Answer 10

unequal

Question 11

Diplopia

Answer 11

Double vision

Question 12

Pinpointed pupils

Answer 12

Narcotics

Question 13

Dilated pupils

Answer 13

Scopolamine patch
Amphetamines
Cough medicine
Cocaine
LSD

Question 14

What are the components of EMV

Answer 14

Eye opening
Motor response
Verbal response

Question 15

Eye opening response

Answer 15

4 spontaneously
3 to speech
2 to pain
1 no response

Question 16

Verbal response

Answer 16

5 oriented to time, person, and place
4 confused
3 inappropriate words
2 incomprehensible sounds
1 no response

Question 17

Motor response

Answer 17

6 obeys commands
5 moves to localized pain
4 flex to withdrawal from pain
3 abnormal flexion
2 abnormal extension
1 no response

Question 18

Decorticate

Answer 18

Problems with cervical spinal tract or cerebral hemisphere

Question 19

Decerebrate

Answer 19

Problems with midbrain or pons

Question 20

Is decorticate or decerebrate worse

Answer 20

Decerebrate is technically worse because it signifies a more profound neurological insult affecting a lower brainstem level

Question 21

What is the accommodation test

Answer 21

Use pen light and bring to patients nose ensuring that their pupils converge and constrict

Question 22

Sensory overload

Answer 22

Reception of multiple sensory stimuli
Pain, lack of sleep, worry, frequent treatments, decreased cognitive ability, irritability, anxiety, restlessness, disorientation, and more.
Nurses should work to modify the environment to the patients liking, control pain, orientation cues, schedule routine of care and prepare client for procedures, and more.

Question 23

Sensory Deprivation

Answer 23

Inadequate quality or quantity of simulation
Private rooms or confinement, isolation, loss of senses, restrictions, emotional withdrawal, drowsiness, impairment memory, disorientation.
Nurse should provide multi sensory stimuli, frequent meaningful interactions, reorient frequently, social stimulation, and more.

Question 24

Presbyopia

Answer 24

Unable to see near objects

Question 25

Cataracts

Answer 25

Clouding of lens

Question 26

Glaucoma

Answer 26

Increase intraocular pressure

Question 27

Macular degeneration

Answer 27

Portion of the retina loses function

Question 28

Diabetic retinopathy

Answer 28

Pathological changes in the blood vessels

Question 29

How to care for patients with visual impairments

Answer 29

Announce presence Stay in their field of vision Explain what you are doing Keep pathways clear Assist with ambulation

Question 30

Presbycusis

Answer 30

Hearing loss due to aging

Question 31

Hearing loss r/t loud noises

Answer 31

Working in a factory Noise induced hearing loss

Question 32

Hearing loss r/t tissue damage

Answer 32

Secondary to repeated infections or ototoxic medications-mycins, furosemide

Question 33

interventions for auditory deficits

Answer 33

Cheating for impacted cerumen Amplification of sounds or flashing lights for safety Slower speech and tones Communication boards Short sentences

Question 34

What are red flag symptoms of a headache

Answer 34

Fever Weight loss Altered mental status Weakness Papilledema Proximal artery tenderness Severe headache triggered by intercourse, cough, or exertion

Question 35

Tension headache

Answer 35

Usually associated with a stressful event/ muscular contraction in the neck and scalp Pressing or tightening pain Occipitofrontal location; bilateral pain Mild to moderate intensity Lack of effect of physical activity Nurse should give necessary medications, encourage rest, massages, etc.

Question 36

Cluster headache

Answer 36

Severe and unilateral Sharp unilateral orbital, supraorbital, or temporal pain accompanied by autonomic symptoms on the affected side. Patient becomes restless Episodes can last 15-180 minutes and occur in increments Nurses should utilize supportive care and pain medication

Question 37

Migraine

Answer 37

Severe disabling, unilateral headaches Described as pulsating Sensitivity to light, sound, and smells, nausea, stiff neck Nursing care includes modifying the environment, start IV, and manage the symptoms