Exam 1

Question 1

A client has just been diagnosed w aneurism, what discharge teaching should be told by the nurse to the client?

Answer 1

Avoid heavy lifting

Question 2

Pt suffering stroke has difficulty swallowing. What to chart?

Answer 2

Dysphagia (G bc esophagus !!)

Question 3

Pt has migraine headache, what can the nurse tell the pt do to minimize these?

Answer 3

Avoid triggers

Question 4

Client has initial TIA, pt states “I’m glad it’s nothing serious”, what should nurse say?

Answer 4

TIA is a warning sign that stroke is to come, let’s talk about lowering your risk

Question 5

Thrombolytic therapy should be initiated during what time frame for ischemic stroke best outcome?

Answer 5

3 hours, up to 4.5 hours

Question 6

A nurse is caring for a pt w/ a cerebral aneurism, what can happen to the pt?

Answer 6

Stimulation can increase ICP

Question 7

What are some health promotion efforts to decrease risk for ischemic stroke?

Answer 7

Low fat diet, low cholesterol, increased exercise

Question 8

Client has a tension headache, so the nurse recommends a massage… how does this help pt?

Answer 8

Relaxes muscles

Question 9

Client brought to ER w/ s/s of CVA (Cerebrovascular Accident)… Nurse wants what diagnostic assessment prior to treatment?

Answer 9

CT scan

Question 10

what is a sign of a suspected stroke?

Answer 10

facial drooping

Question 11

Doctor ordered home health and PT following acute stroke, what to include in discharge?

Answer 11

Meds, dietary concerns

Question 12

A pt is in for a cerebral aneurism & complaining of a severe headache, what should nurse do?

Answer 12

call physician immediately

Question 13

A pt with A-fib is receiving Coumadin to prevent blood clots. The order is 2.5mg daily but they only have a 1mg tablet on hand. How many tablets should nurse give?

Answer 13

2.5 tablets

Question 14

A nurse is taking care of a client w/ difficulty swallowing after a stroke, how do you prevent aspiration?

Answer 14

Assist client into chair, tuck chin to chest when swallowing, speech therapist

Question 15

A nurse is providing care to a pt w/ client that had a stroke, what is symptoms of left sided stroke? aka wernicke`

Answer 15

Expressive aphasia, defects in right sided vision field, problems w/ abstract thinking

Question 16

An ER nurse is caring for a client brought in for a fall, what physical assessment finding shows basilar fracture?

Answer 16

Bruising over mastoid, epistaxis (nosebleed)

Question 17

For a spinal cord injury, neurogenic shock develops below the level of lesion, which indication should nurse expect to find?

Answer 17

Hypotension, Venous pooling, tachypnea (fast breathing), hypothermia

Question 18

Which stimulus is known to trigger autonomic dysreflexia (life threatening hypertension & cardiac arrhythmias) when pt suffered spinal injury?

Answer 18

Putting a blanket over you or having a full bladder provides stimulation which can cause this.

Question 19

Which type of brain injury is characterized by LOC associated w/ stupor (near unconsciousness) and confusion

Answer 19

Contusion

With a contusion,it is a more significant “bruising” of the brain which is followed by a more prolonged loss of consciousness, stupor, and confusion. Contusions can often be seen on CT scans due to the damage. With a concussion, there can be a brief period of loss of consciousness, with mild neurological changes and nothing visible on imaging.

Question 20

Increased ICP caused by traumatic brain injury, what shows increased brain compression causing damage?

Answer 20

Hyperthermia

Question 21

T or F: Osteoporosis results in fractures of the spine, neck, femur, wrists

Answer 21

True (treatment = weight bearing exercises, calcium & vit D, pharmacological treatment -diphosphonate aka Boniva, Alendronate !!!.. educate pt to sit up for an hour straight after they take it w/ 8oz of water, on empty stomach

Question 22

A nurse should recommend short periods of bed rest w prone position (on stomach) resolving form back fracture?

Answer 22

FLASE! should not be prone or on bed rest

Question 23

Staph aureus is the most common organism for this disease

Answer 23

osteomyelitis (infection of bone)

Question 24

this is an injury to ligaments or tendons surrounding muscle around the joint

Answer 24

sprain

Question 25

this is an injury to muscle or tendon due to overwork or over use, also can be due to stretching of the muscle/tendon or a pulled muscle

Answer 25

strain

Question 26

muscle to bone

Answer 26

tendon

Question 27

bone to bone

Answer 27

ligament

Question 28

T or F : Strain is injury to ligaments surround muscle around the joint

Answer 28

last , this is a sprain!

Question 29

T or F: Compartment syndrome is increased pressure that compromises blood flow

Answer 29

true

Question 30

RICE

Answer 30

R: rest I: ice for 20 mins up to 24-72 hrs C: compression E: elevate

Question 31

what is the priority treatment for a pt w/ altered LOC

Answer 31

maintain airway

Question 32

what should the angle of the bed be for mobilizing head for pt w/ ICP

Answer 32

30 degrees

Question 33

GCS numbers

Answer 33

3 = in coma, the worst 15 = normal person

Question 34

this posturing refers to abnormal flexion of upper extremities

Answer 34

decorticate (protecting the core!) vs decerebrate = extending, going away

Question 35

most frequent administered hyperosmotic agent that's used to reduce cerebral edema before intracranial surgery

Answer 35

Mannitol (b/c crosses blood brain barrier)

Question 36

most common cause of intracerebral hemorrhage

Answer 36

hypertension... high risk for developing stroke aka hemorrhagic stroke

Question 37

this condition is the temporary loss of neurological function without damage to brain

Answer 37

contusion

Question 38

what is the most common cause of traumatic brain injury

Answer 38

MVA aka motor vehicle accidents

Question 39

what CN is trigemical neuroglia that's associated w/ sudden pain

Answer 39

CN V: trigeminal

Question 40

this disease, patients have relapses

Answer 40

MS

Question 41

T or F: pt w/ hip fracture should have their legs abducted

Answer 41

False! they should not have their legs crossed, they should be adducted

Question 42

this disease is caused by the inflammation of the 7th CN causing weakness and paralysis on one side

Answer 42

CN VII : Facial nerve which is Bells Palsy disease

Question 43

For hip fx pts using Bucks Traction, where should the weight be?

Answer 43

off the edge of the bed, not handing ON the edge of bed

Question 44

T or F: a nurse has a pt w/ a brain abscess. They will be treated w/ metronidazole (antibiotics for bacterial) alone.

Answer 44

False, b/c it could be bacterial and fungal, so they need to be treated w/ both meds til you get results