Neurologic + Musclskeletal Flashcards
(112 cards)
1
Q
The nurse is reinforcing education to a client newly prescribed levetiracetam for seizures. Which statement made by the client indicates a need for further instruction?
- Drowsiness is a common side effect of this med, will improve over time
- I can begin driving again after I have been on this med for a few weeks
- I need to immediately notify my HCP if I hae new or increased anxiety when on this med
- I need to immediately report any new rash when on this med
A
- I can begin driving again after I have been on this med for a few weeks
Levetiracetam (Keppra) is an anticonvulsant for seizure disorder.
Like any other antiseizure med, it has a depressing effect on the CNS. Drowsiness, somnolence, fatigue.
New or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as levetiracetam is associated with suicidal ideation (Option 3).
Clients with seizure disorder should avoid driving until they have permission from their HCP. (Option 2)
Steven Johnson Syndromemay develop (blisters, rash, muscle/joint pain) while on this med, need to be reported to HCP (Option 4)
2
Q
The nurse assesses a newly admitted adult client on a neurological inpatient unit. Which assessment findings require immediate follow-up by the nurse? Select all that apply.
- Cannot flex chin towards chest
- Eyes move in opposite direction fo head when head is turned to side
- New onset of right arm drift
- Pupils 8 mm in diameter bilaterally
- Toes point downward when sole of foot is stimulated
A
A: 1, 3, 4
1 - Cannot flex chin towards chest = Nuchal rigidity, sign of mengingitis
3 - A new onset of unilateral drift of limb could indicate a stroke!
4 - Normal pupils are 3 - 5 mm in diameter. Pupil dilation can be the result of medication use or neurological causes (Increase ICP, brain herniation).
2 - Oculocephalic reflex (doll’s eyes) is an expected finding indicating an intact brainstem.
5 - Toes point downward when sole of foot is stimulated is an absent Babinski reflex, which is normal for an adult.The babinski reflex is positive for infants up toage 1.
3
Q
A nurse is assessing a 4 week old infant. Which assessment is a sign of right hip developmental dysplasia?
- Decreased right hip adduction
- Presence of extra gluteal folds on right side
- Right leg longer than left
- Right pelvic tilt with lordosis
A
- Presence of extra gluteal folds on right side
Developmental dysplasia of the hip (DDH) is a set of hip abnormalities ranging from mild dysplasia of the hip joint to full dislocation of the femoral head.
DDH is a standard assessment for newborns and infants.
S&S:
Extra inguinal or thigh folds
Laxity of hip joint (Loose hips) on affected side.
4
Q
Alzheimer’s disease maintaing safety for client. SATA:
- Grab bars installed in shower and beside toilet
- Place a safe return bracelet on client’s wrist
- Keyed deadbolts should be placed on all exterior doors
- Meds will be placed in a weekly dispenser
- Throw rugs and clutter removed from floors
A
A: 1, 2, 3, 5
For clients with moderate Alzheimer disease, caregivers should provide a controlled environment for safe wandering (eg, throw rugs and clutter removed, exterior doors secured), and the client should wear an identification/location device (eg, bracelet). All medications should be out of reach or locked away. Hazards (eg, gas appliances, rugs, toxic chemicals) should be removed. Grab bars should be installed in showers and tubs.
5
Q
Bell’s palsy S&S, SATA
- Change in lacrimation of affected side
- Electric shock- like pain in lips and gums
- Flattening of the nasolabial fold
- Inability to smile symmetrically
- Severe pain along the cheekbone
A
A: 1, 3, 4
Manifestations of Bell palsy include:
Inability to completely close the eye on the affected side
Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to weakness of the lower eyelid muscle (Option 1)
Flattening of the nasolabial fold (Between nose and mouth)on the side of the paralysis (Option 3)
Inability to smile or frown symmetrically (Option 4)
6
Q
Which Cranial nerve is affected in Bell Palsy? What is happening to the cranial nerve?
A
Cranial nerve VII (Facial nerve) is affected. The cranial nerve is inflammed.
7
Q
Osteoarthritis - what is it?
A
Osteoarthritis (OA) is a degenerative disorder of the synovial joints (eg, knee, hip, fingers) that causes progressive erosion of the articular (joint) cartilage and bone beneath the cartilage. As the degenerative process continues, bone spurs (osteophytes), calcifications, and ulcerations develop within the joint space, and the “cushion” between the ends of the bones breaks down.
8
Q
S&S of Osteoarthritis
A
Pain exacerbated by weight-bearing activities: Results from synovial inflammation, muscle spasm, and nerve irritation
Crepitus, a grating noise or sensation with movement that can be heard or palpated: Results from the presence of bone and cartilage fragments that float in the joint space
Morning stiffness that subsides within 30 minutes of arising
Decreased joint mobility and range of motion
Atrophy of the muscles that support the joint (eg, quadriceps, hamstring) due to disuse
9
Q
Client in motor vehicle collision reports severe pelvic and right heel pain. Which assessment is priority and reported to HCP?
- Distended abdomen and absent bowel sounds
- Ecchymosis over the pelvic bones
- Hbg of 11.5, hematocrit of 34%
- Tenderness over the right heel
A
The pelvis contains several large vascular structures (eg, internal and external iliac veins and arteries) and abdominal and pelvic organs (eg, small bowel, sigmoid colon, bladder, urethra, uterus, prostate).
So when caring for a client with a fractured pelvis, in addition to pain, the nurse should assess for internal hemorrhage, paralytic ileus,neurovascular deficits and abd and GU organ injuries.
Abdominal distension could be due to serious intra-abdominal bleeding or injury to the bowel or urinary structures. Absent bowel sounds can indicate paralytic ileus. These should be reported to the HCP
10
Q
Hungtingon Disease - What type of inheritance disease is it?
A
Hungtington disease is an incurable autosomal dominant hereditary disease that causes progressive nerve degeneration.
This means if the one of the parents have it, there’s a 50% chance that the children will have it as well.
Clients who have a parent with HD and are considering having biological children should receive genetic counseling
11
Q
Cranial nerve IX - what is it?
A
Cranial nerve IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste.
12
Q
Which assessment finding indicate spinal immobilization?
- Breath of alcohol
- Client disoriented to place
- Client reports eyes burning
- Hx of MS
- Point tenderness over spine
A
A: 1, 2, 5
An acronym to help determine spinal immobilization (NSAID):
N - Neurological examination. Focal deficits include numbness and decreased strength.
S - Significant traumatic mechanism of injury
A - Alertness. The client may be disoriented or have an altered level of consciousness (Option 2).
I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option 1).
D - Distracting injury. Another significant injury could distract the client from spinal pain.
S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present (Option 5).
13
Q
The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant health care provider notification?
- I am going for my gaucoma appointment
- I am not able to exercise as much as I need to
- I started taking esomeprazole for heartburn
- My BMs are not regular
A
- I am going for my glaucoma appointment
Anticholinergic medications (eg, benztropine, trihexyphenidyl) will have a drying effect on eyes.
No spit, no see, No pee, No shit.
So it is contraindicated for glaucoma patients!
14
Q
Carpel Tunnel syndrome - treatment?
A
Most clients with CTS can conservatively manage symptoms with wrist immobilization splints (Option 4).
Splinting and immobilization of the wrist (particularly during sleep) reduces pain by preventing flexion or extension and subsequent nerve compression.
15
Q
Which statement by a client scheduled for a lumbar puncture indicates a need for further teaching by the nurse?
- I may feel a sharp pain that shoots to my leg, but should pass soon
- I will empty my bladder before the procedure
- I will need to lie on my stomach during the procedure.
- The physician will insert a needle between the bones in my lower spine.
A
- I will need to lie on my stomach during the procedure.
Prior to a lumbar puncture, clients are instructed as follows:
Empty the bladder before the procedure (Option 2)
The procedure can be performed in the lateral recumbent position or sitting upright. These positions help widen the space between the vertebrae and allow easier insertion of the needle (Option 3).
A sterile needle will be inserted between the L3/4 or L4/5 interspace (Option 4)
Pain may be felt radiating down the leg, but it should be temporary (Option 1)
After the procedure, instruct the client as follows:
Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache
Increase fluid intake for at least 24 hours to prevent dehydration
16
Q
Buck traction maintenance, which of the following are incorrect?
- Elevates head of bed 45 degrees
- Holds the weight while cleint is repositioned up in bed
- Loosens the Velcro straps when the client reports that the boot is too tight
- Provides the client with a fracture pan for elimination needs.
A
- Elevates head of bed 45 degrees
The client’s headshould not be elevated more than 30 degrees (semi-Fowlers), because more than 30 degrees would promote sliding down the bed! (Option 1)
Regularly neurovascular assessment and skin assessment of the limb in traction is correct (Option 3)
Weights should be supported during repositioning. Weights should never touch the bed or the floor! (Option 2)
Fracture pan is nessessary for bed bound patients for elimination (Option 4)
17
Q
A client was awake and had a BP of 160/80 with a pulse of 70. An hour later, the client is lethargic, BP 200/80, HR 48. What should bethe nurse’s next action?
- Admin atropine for bradycardia
- Admin nifedipine for HTN
- Have CT scan to rule out intracranial bled
- Perform hourly neurologic check with GCS
A
- Have CT scan to rule out intracranial bled
This client has signs of Cushing’s triad:
bradycardia, increased systolic blood pressure with a widening pulse pressure (difference between systolic and diastolic), and slowed irregular (Cheyne-Stokes) respirations.
Cushing’s triad indicates a brain stem compression.
In this scenario, hidden head trauma causing an intracranial bleed must be ruled out with diagnostic testing.
Medication admin is not appropriate in this case because the meds atropine and Nifedipine do not have a etiological reason for administration. (Option 1, 2)
Neuro assessment is nessesary, but not the priority. (Option 4)
18
Q
Multiple Sclerosis - Ambulation
Which of the following instructions by the nurse would be most appropriate regarding the client’s incoordination when walking?
- Avoid excess stretching of your lower extremities
- Build strength by increasing daily exercises
- Let me speak with your health care provider about getting a wheelchair
- You should keep your feet apart and use a cane when walking.
A
- You should keep your feet apart and use a cane when walking.
Walking with the feet apart increases the support base, improving steadiness and gait. Assistive devices, such as a cane or walker, are usually required as demyelination of the nerve fibers progresses. (Option 4)
Range of motion, strengthening, stretching exercises help limit contractures and spasticity in MS. (Option 1)
Fatigue is common in MS, so balacing exercise and rest is more appropriate than to lengthen exercises. (Option 2)
Wheelchairs are not recommended for MS clients as we want to promote independence and mobility. (Option 3)
19
Q
The nurse observes a novice nurse caring for a client experiencing status epilepticus. It will require immediate intervention if the novice nurse does which of the following?
A. Prepares to administer intravenous valproate.
B. Places the client in a lateral position.
C. Activates the rapid response team (RRT).
D. Loosens any restrictive clothing.
A
A. Prepares to administer intravenous valproate.
Valproate is used as a prophylaxis (antiepileptic) medication to prevent seizures. Intravenous benzodiazepines such as lorazepam, diazepam, or midazolam should be promptly administered to this client. These medications help terminate the seizure.
20
Q
The nurse is assessing a patient’s neurological status and notes 4+ deep tendon reflexes (DTR). Which of the following conditions would not be a possible cause of hyperactive DTRs?
A. Hypocalcemia
B. Muscular dystrophy
C. Upper motor neuron lesion
D. Hyperthyroidism
A
B. Muscular dystrophy
Think: Duchenne Muscular Dystrophy (DMD), the muscle weakens, therefore less tendon reflexes.
Hyperactive deep tendon reflexes (DTRs) would not be expected in a patient with muscular dystrophy. Muscular dystrophy DTRs are typically decreased or absent.
21
Q
A client who has sustained a sports injury just underwent a diagnostic arthroscopy of the left knee. Which of the following should the nurse prioritize assessing after the procedure?
A. Wound and skin integrity
B. Mobility assessment
C. Skin and vascular assessment
D. Circulatory and neurologic assessments
A
D. Circulatory and neurologic assessments
The priority would be to assess the neurological and circulatory status of the extremity and ensure that they are intact. Following an arthroscopy, swelling may occur in the affected limb due to the extravasation of fluid in the leg. Such fluid accumulation increases the compartment pressures and carries a risk of compartment syndrome.
22
Q
The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect? Select all that apply.
A. Unilateral frontotemporal pain
B. Nausea
C. Photophobia
D. Fever
E. Nuchal rigidity
F. Vomiting
A
Answer: A, B, C, F
The most common manifestations associated with an acute migraine headache include:
Unilateral frontotemporal pain that may be described as throbbing or dull
Sensitivity to light (photophobia) and sound (phonophobia)
Nausea and/or vomiting
Altered mentation (drowsiness)
Dizziness, numbness, and tingling sensations
D, E are signs and symptoms of Meningitis
23
Q
The nurse performs a focused assessment on a casted patient experiencing increased pain in the affected limb. The nurse notes pallor and swelling distal to the cast area. The patient reports increased pain upon passively moving the extremity. Which of the following fracture-related complications should the nurse be concerned about?
A. Fat embolism
B. Infection
C. Pulmonary embolism
D. Compartment syndrome
A
D. Compartment syndrome
Compartment syndrome = pressure increases, increasing pain, passive pain when moved, pale swollen tissue distal to site (Circulation cut off, pedal pulses will be faint)
24
Q
The nurse is caring for a patient with Huntington’s disease. Which of the following assessment findings would be expected? SATA
A. Halitosis
B. Chorea
C. Hallucinations
D. Hematemesis
E. Weight loss
A
Answer: B, C, E
Chorea - involuntary movements of trunk, limbs and face
Hallucinations as well as paranoia, delusions, depression are common with Huntington’s disease
Weight loss is also a common finding as the excessive movements = excessive energy loss
Halitosis = bad breath
Hematemesis (Vomiting blood) is not a sign of Hungtington’s
25
The nurse is assessing a patient with suspected neurological issues. The patient’s speech is delivered with normal rhythm but filled with words that do not form any meaningful statements. The patient is also unable to write or repeat back words and does not appear to understand the nurse’s instructions or questions. The nurse would recognize these symptoms as:
A. Broca’s aphasia
B. Global aphasia
C. Expressive aphasia
D. Wernicke’s aphasia
D. Wernicke’s aphasia
It is characterized by the ability to produce verbal language but mix similar sounding words so that speech is often incomprehensible. Reading, writing, oral comprehension, and repetition are affected.
26
The nurse is assessing a client who is suspected of having myasthenia gravis. Which of the following would be an expected finding? Select all that apply.
A. Diplopia
B. Butterfly rash
C. Facial muscle weakness
D. Shuffling gait
E. Ptosis
Answer: A, C, E
Key clinical features of myasthenia gravis (MG) include diplopia (double vision), ptosis (Drooping eye lid), facial muscle weakness, and may progress to respiratory failure.
27
The nurse is caring for a patient who is experiencing status epilepticus. Which of the following actions should be prioritized by the nurse? SATA
A. Administer prescribed carbamazepine.
B. Notify the rapid response team (RRT).
C. Obtain a prescription for lorazepam.
D. Loosen any restrictive clothing.
E. Review the client's most recent phenytoin level.
Answer: B, C, D
The RRT should be notified as this is a medical emergency and requires evaluation by the RRT team.
Obtaining a prescription for a parenteral benzodiazepine such as lorazepam is appropriate. Benzodiazepines are key in terminating a seizure.
Placing clients on their side and loosening any restrictive clothing is appropriate and a priority.
Reviewing lab values is not a priority during a medical emergency. Carbamazepine is a maintenance drug used for seizure prevention, not for an emergency.
28
The nurse is preparing a patient for scheduled total knee arthroplasty (TKA). Which action by the nurse would be most important to reduce this patient’s risk for experiencing emergence excitement after this procedure?
A. Ask the patient about any concerns regarding the procedure.
B. Monitor for changes in the patient’s respiratory status.
C. Reassure the patient that this is a simple, minor procedure.
D. Ask the patient about any recent alcohol and drug use.
A. Ask the patient about any concerns regarding the procedure.
Reducing the patient's anxiety before a procedure will reduce the patient's risk of developing emergence excitement (Delirium). The nurse should provide reassurance, explain the purpose of procedure, and allow the patient to express concerns/ask questions.
Choice D is incorrect. Patients with a history of recent drug or alcohol use may be at increased risk of post-operative emergence excitement, but this action would only identify the risk factor, not actively reduce the patient’s risk of experiencing this problem.
29
A 24 y/o woman presents to the ED and appears to have "Raccoon's eyes". What type of injury does this assessment finding suggest?
A. CSF leak
B. Basilar skull fracture
C. Brown-sequard syndrome
D. Subarachnoid hemorrhage
B. Basilar skull fracture
Pooling of blood surrounding the eyes (retroorbital ecchymosis) is most often associated with fractures of the anterior cranial fossa or basilar skull fracture.
30
Avulsion fracture - what is it?
A fracture that pulls a part of the bone from the tendon or ligament
31
Which position while sleeping should a patient with acute low back pain avoid? Which position should the patient be sleeping in?
Avoid sleeping in the prone position
| They should be sleeping in a side lying or supine position
32
A nurse is caring for a patient with Meniere's disease, which of the following nursing interventions should the nurse implement as the highest priority?
A. Discussing treatment options
B. Initiating fall risk measures
C. Keeping the patient calm during an episode
D. Providing teaching on potential causes
B. Initiating fall risk measures
Since Meniere’s disease causes vertigo or the feeling that one is spinning, the patient is at an increased risk for falls. To keep this patient safe, the nurse must initiate fall risk measures.
33
The nurse is planning a staff development conference on the prevention of contractures. Which of the following information should the nurse include?
SATA
A. Range-of-motion exercises of the extremities help prevent contractures.
B. Splinting the extremities may increase the risk of contractures.
C. Too many pillows under the head may cause a neck flexion contracture.
D. Using multiple staff members to reposition a client may prevent a contracture.
E. Contractures after a hip arthroplasty can be prevented with an abduction pillow.
Answer: A, C
Range of motion exercises are essential in preventing contractures. Having a client engage in ROM exercises inhibits disuse and atrophy, which drives a contracture. Too many pillows under the neck cause neck flexion, which may cause a contracture.
Splints - prevents contracture by providing support, stability and alignment
Multiple staff reposition client ≠ prevention of contracture
An abduction pillow may be used after a hip arthroplasty to prevent dislocation of the joint – not a contracture.
34
A nurse is caring for a client who sustained a cervical spinal cord injury. Which of the follow is a priority vital sign?
A. Respiratory rate
B. Blood Pressure
C. Pulse
D. Temperature
A. Respiratory rate
Respiratory rate is essential to monitor when a cervical spinal cord injury is sustained. The upper cervical spinal nerves innervate the diaphragm to control breathing.
35
Which of the following findings is consistent with rheumatoid arthritis?
A. Janeway lesions
B. Tophi
C. Unilateral joint pain
D. Low-grade fever
D. Low-grade fever
Low-grade fever is a manifestation of inflammation. Rheumatoid arthritis causes inflammation of the joints.
36
The nurse is caring for a client who has just returned from external fixation device placement for stabilization of a fractured femur. Which of the following interventions are appropriate to include in the client's plan of care? Select all that apply.
1. Assess for increased drainage from pin site
2. Check for loose pins and tighten them if loose
3. Maintain bed rest until device removed
4. Monitor pulses distal to external fixation device
5. Perform pin care with sterile cleaning solution
Answer: 1, 4, 5
The nurse can help prevent infection and maintain extremity and device integrity by:
Assessing the pin sites regularly for new, increased, and/or purulent drainage and checking the skin surrounding the pins for erythema, warmth, pain, or breakdown (Option 1)
Assessing for signs of compartment syndrome (eg, decreased pulses, coolness, pain, numbness) (Option 4)
Performing pin site care with a sterile cleaning solution (eg, chlorhexidine, sterile normal saline) and gauze (Option 5)
Monitoring pins and device for loosening and reporting to the health care provider (HCP) if they are loose
37
A client sustained a concussion after falling off a ladder. What are essential instructions for the nurse to provide when the client is discharged from the hospital? Select all that apply.
1. The client should abstain from alcohol
2. Client should remain awake all night
3. Client should return if having difficulty walking
4. Responsible adult should be taught neurological exam
5. Responsible adult should stay with client
Answer: 1, 3, 5
An essential aspect of discharging a client with a head injury is ensuring that a responsible adult will check on the client as the level of consciousness can change (Option 5).
Brain edema or increased intracranial pressure (IICP) may not be evident immediately. The client should return to the emergency department or notify the primary care provider if:
Changes in LOC, worsening headache, visual changes, motor problems (Option 3), sensory disturbances, seizures, N/V, bradycardia
Alcohol will decrease the LOC, so it should be abstained (Option 1)
38
The new graduate nurse provides care for a client with a halo external fixation device. Which actions by the new nurse are appropriate? Select all that apply.
1. Clean around pins with sterile water
2. Gently tighten device screws if they become loose
3. Holds the frame of the device when logrolling the client
4. Places a small pillow under the head when client is supine
5. Uses a blow-dryer on the cool setting to dry the vest when wet
Answer: 1, 4, 5
Care for the client with a halo device includes:
Cleaning pin sites with sterile solution (eg, chlorhexidine, water) to prevent infection (Option 1)
Keeping the vest liner clean and dry (eg, changing weekly or when soiled, using a cool blow-dryer to dry) to protect the skin (Option 5)
Placing foam inserts under pressure points to prevent pressure injury
Placing a small pillow under the client's head when supine to reduce pressure on the device (Option 4)
Keeping the correct-sized wrench available at all times in case of emergency
39
A client develops ankle pain and swelling, diagnosis of lateral ankle sprain. Which interventions does the nurse include in the discharge instructions? Select all that apply.
1. Apply heat to reduce welling during the first 24 hrs
2. Begin an exercise rehabilitation program when the pain subsides
3. Elevate the leg above the heart level on 2 pillows
4. Flex and dorsiflex the foot to prevent stiffness during the first 24 hrs
5. Take ibuprofen every 6 hours as needed
6. Wrap the ankle with an elastic compression bandage
Answer: 2, 3, 5, 6
Exercise rehabilitation program – This should be initiated as soon as possible after the injury (ie, when pain subsides) to restore range of motion, flexibility, and strength and prevent reinjury (Option 2).
Analgesia – Mild analgesia with a nonsteroidal anti-inflammatory drug (eg, ibuprofen) can be taken every 6 hours as needed to relieve pain and reduce swelling (Option 5).
For sprains, follow the R.I.C.E protocol.
Rest, Ice, Compress, Elevate (Option 3, 6)
40
Which nursing problem for a client with Alzheimers would be the nurse's primary concern?
A. Inability to do activities of daily living.
B. Increased risk for injury.
C. Potential for constipation.
D. Ineffective family copin
B. Increased risk for injury.
Safety should be the highest priority for the client. Clients with Alzheimer’s disease are unaware of their surroundings and tend to wander. The nurse should implement safety measures.
41
Which of the following regarding neural tube defect are true?
A. Types of neural tube defects include spina bifida occulta, spina bifida cystica, meningocele, and myelomeningocele.
B. The nurse should protect the exposed sac by covering with a sterile, moist, non-adherent dressing.
C. Left-lateral is the optimal position to minimize tension on the sac.
D. Neurological deficits are always present in patients with neural tube defects.
Answer: A, B
Spina bifida occulta, spina bifida cystica, meningocele, and myelomeningocele are the types of neural tube defects (Choice A). If there is exposed spinal cord or meninges in a sac, it is essential to cover them with a sterile, moist, non-adherent dressing. This prevents infection and maintains the moisture of the pouch containing the spinal cord and meninges (Choice B).
Prone is the best position to place the infant. (Choice C)
Neurological deficits are not present with all neural tube defects (Choice D)
42
A patient presents to the emergency department following a motor vehicle accident. The nurse assesses that the patient is unable to move legs and has poor reflexes. What additional assessment data would support the diagnosis of spinal shock?
A. Hypotension
B. Decreased sensation
C. Bradycardia
D. Upper extremity motor weaknes
B. Decreased sensation
Symptoms of spinal trauma include decreased sensation, decreased reflexes, and flaccid paralysis below the level of the spinal cord injury.
Hypotension and bradycardia are S&S of neurogenic shock.
43
Of the following, which conditions would the nurse recognize as potential sources of neuropathic pain?
Select all that apply.
A. Spinal tumor
B. Arthritic joint
C. Muscle strain
D. Shingles
E. Kidney stones
Answer: A and D
Neuropathic pain describes constant inflammation or irritation of nerve cells that causes pain sensation due to oversensitive nerve cells
Ex: CNS lesions, stroke, tumor, multiple sclerosis, sciatica, shingles, and phantom limb pain.
44
A 28-year old woman presents to the trauma bay after being shot in the upper back. She can move the left side of her body but is unable to move the right. However, she cannot feel any pain on the left. The nurse knows these symptoms are suggestive of which type of spinal cord injury?
A. Incomplete spinal cord injury, central cord syndrome
B. Incomplete spinal cord injury, Brown-Sequard syndrome
C. Complete spinal cord injury, paraplegia
D. Complete spinal cord injury, anterior cord syndrome
B. Incomplete spinal cord injury, Brown-Sequard syndrome
Brown-Sequard syndrome is an incomplete spinal cord injury.
Meaning the weakness/paralysis on the affected side and a sensory loss on the opposite side of the body below the level of injury.
Central cord syndrome means neurological deficit in upper extremities (because the central cords/ cervical spinal cord innervates the hands and arms)
Anterior cord syndrome is an incomplete spinal cord injury, with a loss of pain/ temperature.
45
Stage 1, 2, 3 dysphagia - What are they?
Stage 1 dysphagia means the client has severe difficulty in swallowing. They must be fed with puree foods (ex: Pureed furits, veges, pureed meats with gravy, egg yolks, baby foods).
Stage 2 dysphagia means the client can tolerate moist and soft-textured foods (ex: well-cooked veges, tender meat, scrambled/ soft cooked eggs) that are easy to chew.
Stage 3 dysphagia means the client can tolerate foods of regular texture, with the exception of very hard, sticky or crunchy foods.
46
The nurse writes the following care plan for a patient with epilepsy. Based on the care plan, which interventions would be appropriate for the nurse to include?
Select all that apply.
A. Remove hard or sharp objects from the patient’s environment
B. Place a bite block during seizure activity
C. Monitor compliance in taking antiseizure medications
D. Apply padded side rails to the bed
E. Position the patient in a side-lying position
Answer: A, C, D, E
A: Hard or sharp objects should be removed from this patient’s environment to reduce the risk of injury during seizure activity.
C: Monitoring compliance with antiseizure medications is an important intervention to determine this patient’s risk for seizure activity.
D: Padding the siderails of the bed would be an appropriate intervention to reduce this patient’s risk of injury in the event of a seizure.
E: Placing the patient in a side-lying position reduces the risk of aspiration when the client is in a post-ictal state, thus preventing injury.
47
The orthopedic nurse is providing teaching to a patient who is scheduled to be placed in a plaster cast. Which of the following instructions are most important to give the patient once the cast has been applied?
A. Use a small object like a pencil or ruler to itch the leg if it becomes uncomfortable.
B. Expedite drying by using a hot blow dryer on the cast once at home.
C. Let the cast hang below the heart to promote blood flow.
D. Handle the cast with the palms of the hands rather than the fingers.
D. Handle the cast with the palms of the hands rather than the fingers.
Handling the cast with fingers may pose the risk of patient developing compartment syndrome
Objects should not be stuck down into the cast. Objects could cause scratches beneath the cast and lead to infection. (Option A)
While a hairdryer may be used to assist in drying, it should be used at a cooler setting, not hot. A hot dryer could cause hot spots on the affected limb. (Option B)
Elbow should be elevated to reduce edema (Option C)
48
Which questions should be included during the interview of both mother and child who developed Lyme disease?
A. “Have you noted any flank pain and a decrease in the volume of urine?”
B. “Has there been a fever of over 103 degrees F over the last 2-3 weeks?”
C. “Did you notice rashes on the palms and soles?”
D. “Do you have headaches, malaise, or sore throat?”
D. “Do you have headaches, malaise, or sore throat?”
Typical symptoms of Lyme disease:
Swelling of knees
Bull's eye rash at bite mark
Flu-like symptoms such as headache, body malaise, and unexplained fatigue
49
The nurse assesses a client with damage to cranial nerve III. Which finding would be expected?
A. Ptosis
B. Anosmia
C. Uvula deviation
D. Asymmetric facial movement
A. Ptosis
Ptosis = drooping of eye
Cranial nerve 3 = oculomotor, "eye moving"
Dysfunction of cranial nerve III is also associated with dilated pupil, absent light reflex, and impaired extraocular muscle movement.
50
The nurse is caring for a client with Multiple Sclerosis (MS) undergoing plasmapheresis. The nurse understands that plasmapheresis controls symptoms of MS by removing which of the following elements from the blood?
A. Catecholamines
B. Antibodies
C. Plasma proteins
D. Lymphocytes
B. Antibodies
Multiple sclerosis (MS) is a disease wherein antibodies attack the myelin sheath of the neurons causing MS symptoms. In plasmapheresis, these antibodies are removed from the client’s plasma, removing the cause of myelin sheath demyelination.
51
The nurse is caring for an infant with developmental dysplasia of the hip (DDH). Which of the following prescriptions would the nurse anticipate from the primary healthcare provider (PHCP)?
A. Pavlik harness
B. Compression hose
C. Knee immobilizer
D. Continuous passive motion
A. Pavlik harness
Developmental dysplasia of the hip means the ball/socket of the femur is not properly formed, the socket may be loosely attached or dislodged.
The Pavlik harness is utilized for the treatment of DDH. The goal of the therapy is to keep the hips abducted as much as possible.
52
You are a home health nurse caring for an elderly client in her home. She has children and grandchildren. However, they live far from the couple and they typically visit only once or twice a year. The client is beginning to show some signs of Alzheimer’s. The husband is 88-years-old and had a stroke that left him with right-sided weakness. What support should you give the husband in terms of caring for his wife?
A. You should advise the couple to move closer to their children so that they can care for their father.
B. You should teach the husband about the progression of Alzheimer’s and the need to promote as much independence as possible.
C. You should teach the husband about this progressive disease and the need to do all that he can for his wife to help prevent anxiety and depression.
D. You should advise the couple to decrease their social activities in order to preserve the wife’s dignity and self-esteem.
B. You should teach the husband about the progression of Alzheimer’s and the need to promote as much independence as possible.
Dementia can limit a person's ability to live independently, which can be very distressing for the individual and family members. Caregivers need to embrace a patient-centered approach that allows people with dementia to maintain as much autonomy and control as possible, while still preserving their safety.
53
The nurse notices some bright red blood on the residual limb dressing of a client that had a below-the-knee amputation. The nurse suspects an arterial bleed. What should be the nurse’s first action?
A. Increase the IV rate.
B. Take the client’s vital signs.
C. Apply a tourniquet above the amputation.
D. Notify the physician.
C. Apply a tourniquet above the amputation.
Arterial bleeding is very severe and urgent type of bleeding. The bleed is almost pulsating/jumping out. The patients will bleed out very quickly.
The nurse should apply a tourniquet above the client’s residual limb to stop the bleeding. This should be the nurse’s first intervention.
54
The nurse is planning care for a client with a newly diagnosed fractured pelvis. Which action would lessen the risk of fat embolism syndrome (FES)?
A. Request a prescription for enoxaparin.
B. Alternate with the application of ice and heat.
C. Educate the client on pelvic immobilization.
D. Encourage passive range of motion of the lower legs.
C. Educate the client on pelvic immobilization.
No specific treatment with suspected fat emboli. But the most effective way to prevent fat embolism syndrome (FES) is aggressive immobilization.
55
Which of the following information would NOT be included in a client's pain history?
A. The client’s affective responses to pain
B. The client’s past alleviating measures
C. The client’s current vital signs
D. The client’s meaning of pain
C. The client’s current vital signs
The client’s current vital signs would NOT be included in a client's pain history.
Meaning of pain (Option D), past alleviating pain measures (Option A), affective responses to pain are part of a client's pain history.
56
The nurse is taking care of an 8-hour post-operative spinal surgery client. What should be the priority nursing intervention for the client?
A. Assess how much opioid analgesics the client is using via the patient-controlled analgesia (PCA) pump.
B. Logroll the client with three staff when turning the client from side to side.
C. Assist the client in ambulating to the bathroom.
D. Place pillows under the thighs of each leg when the client is in the supine position.
B. Logroll the client with three staff when turning the client from side to side.
Preventing post op complications is a priority!
Logrolling the client is a priority to maintain proper body alignment and prevent injury to the spinal cord.
Client is on bed rest for the first 24 hours after spinal surgery, so ambulation is not a priority. (Option C)
57
Pt developed an acute hemorrhagic stroke. Which nursing intervention is appropriate? SATA
1. Admin PRN stool softeners
2. Admin scheduled enoxaparin
3. Implement sizure precautions
4. Keep pt NPO until swallow screen performed
5. Perform frequent neurological assessments
A: 1, 3, 4, 5
Anticoagulants are contraindicated in clients with hemorrhagic stroke (Option 2)
Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should:
Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors
Administer stool softeners to reduce strain during bowel movements (Option 1)
Reduce exertion, maintain strict bed rest, assist with activities of daily living
Maintain head in midline position to improve jugular venous return to the heart
Seizure activity may occur due to increased intracranial pressure (ICP) (Option 3).
To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits (Option 4).
Neuro assessments are needed to monitor for acute changes (Option 5)
58
The nurse teaches a client with Boston brace. Which instruction should the nurse include?
1. Apply body lotion or powder under brace to prevent skin irritation
2. Avoid any exercise that use spinal muscles
3. Keep brace on at all times, even during showers
4. Wear a cotton t-shirt under the brace at all times
4. Wear a cotton t-shirt under the brace at all times
Boston brace is used to diminish the progression of deformed spinal curves in scoliosis.
Due to the risk for skin breakdown, clients should wear a cotton t-shirt under the brace to decrease skin irritation and absorb sweat.
Compliance is a major problem in most adolescents as they are preoccupied with body image and appearance. Psychosocial issues (eg, body image, sense of control, socialization) are very important to discuss.
The use of lotion or powder can cause skin irritation due to heat buildup beneath the brace. (Option 1)
It is important to build and maintain strength in the spinal muscles to promote stabilization throughout treatment. The client can take the brace off for a few hours throughout the day (Option 2)
Most braces are worn for 18-23 hours per day and removed for bathing and exercise. (Option 3)
59
Hip fractures the S&S? SATA
1. Ecchymosis over the thigh and hip
2. Groin and hip pain with weight bearing
3. Internal rotation of affected extremity
4. Muscle spasm around the affected area
5. Shortening of the affected extremity
A: 1, 2, 4, 5
The most common clinical manifestations of hip fractures include:
Ecchymosis and tenderness over the thigh and hip (Bleeding into surrounding tissues)
Groin and hip pain with weight bearing (Option 2)
Muscle spasm in the injured area – occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area (Option 4)
Shortening of the affected extremity – occurs because the fracture can reduce the length of the bone and the muscles above the fracture line pull the extremity upward (Option 5)
60
What is Amyotrophic lateral sclerosis (ALS)?
Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurodegenerative disease with no cure. ALS causes progressive degeneration of motor neurons in the brain and spinal cord.
Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure
61
The client ingested extra methadone tablets for chronic severe back pain.
Which assessment findings during discharge require the client to be monitored longer in the hospital?
SATA
1. Client falls asleep while the nurse is talking
2. Client frequently scratches due to pruritus
3. Client has third emesis since taking medication
4. Monitor reveals one premature ventricular contraction
5. Pulse oximeter shows SpO2 90%
A: 1, 3, 5
Methadone is a narcotic
Early signs of toxicity include nausea/vomiting and lethargy. (Options 1 and 3)
A reading of 90% is low and indicates inadequate depth or rate of respiration with possible respiratory depression (Option 5).
62
The nurse is assessing a 4-year-old boy, which symptoms are a concern for Duchenne Muscular Dystophy?
SATA
1. Frequent trips and falls at home
2. Has painful knees and elbows in morning
3. Places hands on thighs to push up to stand
4. Sudden ridgily extends the arms and legs
5. Walks on tiptoes and has disproportionately large calves.
A: 1, 3, 5
Children with Duchenne muscular dystrophy raise themselves to a standing position using the classic Gower sign/maneuver (placing hands on the thighs to push up to stand) and walk on tiptoes (Options 3 and 5). Parents may also report frequent tripping and falling (Option 1).
Joint pain worse in morning is a symptom of juvenile idiopathic arthritis
Ridgid extension of arms and legs is seen in tonic-clonic sizure.
63
You are taking care of an infant newly diagnosed with hydrocephalus. Which of the following assessment findings do you expect?
Select all that apply.
A. Increased head circumference
B. Macewen’s sign
C. Sunken anterior fontanelle
D. Setting sun eyes
Answer: A, B, D
Macewen’s sign is an indication of hydrocephalus. This sign is positive when the nurse percusses the skull bones and hears a ‘cracked-pot’ sound. This sound is due to thin, widely separated skull bones present with hydrocephalus.
Setting sun eyes is an assessment finding found in children with hydrocephalus that has progressed so far it is causing increased ICP. The child looks as if they are always looking down with more prominent sclera in the top part of their eyes.
64
The nurse is caring for a client receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response?
A. Nervousness
B. Warm sensation
C. Angina
D. Tingling sensation
C. Angina
Angina is a concerning finding and requires follow-up by the nurse. Vasoconstriction may occur with this medication, and thus, the client with a medical history of coronary artery disease, uncontrolled hypertension, and a previous stroke should not take this medication.
Sumatriptan is a medication indicated to treat migraine headaches. It is not a prophylactic treatment.
65
You are a nurse in the emergency department of a local hospital. You are caring for a 60-year-old man with a sudden-onset headache that he describes as, “The worst headache of my life.” You know that red flags for this problem include:
Select all that apply.
A. Confusion
B. Nuchal rigidity
C. Hypotension
D. Age greater than 50 years
Answer: A, B, D
Red flags for headaches include confusion, nuchal rigidity, age greater than 50 years (or less than five years).
Hypertension is another red flag, not hypotension.
66
What is Hypophysectomy? - what are its complications?
Hypophysectomy is the removal of the pituitary gland.
A complication of Hypophysectomy is the development of Diabetes Insipidus. (Because the removal of the pituitary gland means there's no regulation of the diuretic hormone.
An hourly output of 125 mL would be considered polyuria, (3000mL in 24 hrs) and need to be reported to the physician.
67
The nurse observes a client with dementia not recognizing their family member. The nurse understands that this client is demonstrating signs of which of the following?
A. Apraxia
B. Agraphia
C. Agnosia
D. Aphasia
C. Agnosia
Agnosia = inability to identify familiar objects or people, spouse.
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Apraxia = the inability to perform familiar and purposeful tasks.
Agraphia = a term describing when a client has difficulty writing
Aphasia = the difficulty finding the correct word
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68
A cast is applied to a thirteen-month-old girl for the treatment of talipes equinovarus (clubfoot). Which of the following instructions should the nurse give the child’s mother regarding the child's care while in the cast?
Select all that apply.
A. “It is important to do frequent skin checks around the edges of the cast.”
B. “Pay attention if your child expresses discomfort that may suggest numbness or tingling in her toes."
C. “Reassure your child that this type of cast will be removed in a week for good.”
D. “Check the temperature and color of the skin on your child’s feet.”
E. “Ask the child once per day if she feels that the cast is too tight.”
F. “Call the doctor if the child has pain unrelieved by medication.”
Answer: A, B, D, F
Choices A and D: Skin checks around the edges of the cast are an excellent way to check for impaired circulation. Assessing the color and temperature of the skin will help determine any circulatory compromise.
Choice B: Although the thirteen-month-old may not use the words numbness or tingling, they can likely express discomfort, which should be assessed.
Choice F: Any time pain is persistent and unrelieved by medication, the physician should be notified.
The cast is reapplied weekly (Choice C), the child will likely tell the parent if the cast is too tight (Choice E)
69
What is donepezil? What is it used to treat?
Donepezil is an acetylcholinesterase Inhibitor, it is used to treat alzheimer's
70
The nurse is providing instructions to the family members of a diabetic patient who has just received a right-side below the knee amputation (BKA). The nurse should inform the family to watch the patient closely for which of the following concerning issues?
A. The development of an upper respiratory infection
B. Wound dehiscence
C. Swelling of the left leg
D. Redness at the surgical site
B. Wound dehiscence
Diabetes mellitus is known to cause delayed wound healing because of damage to the body’s blood vessels.
Wound dehiscence occurs when the wound’s edges break open at the site.
71
Lead cause of cognitive impairment in old age
Alzheimer's disease
72
A 7-year-old child is brought to the emergency department because of a fall. A fractured arm was confirmed and a plaster cast was applied. The nurse is providing instructions to the child’s mother regarding the cast. Which statement by the mother necessitates further instructions from the nurse?
A. “As the cast dries, it can feel a bit warm.”
B. “I’ll just put some powder or lotion on the edges of the cast in case my child complains of an itch.”
C. “I can use shoe polish to clean the cast.”
D. “I can use a blow dryer on the cool setting to dry the cast in case it gets wet.”
B. “I’ll just put some powder or lotion on the edges of the cast in case my child complains of an itch.”
The patient is not allowed to put lotion or powder into the cast as it may be sticky and cause skin irritation.
73
A client had below the knee amputation, and complaining of phantom limb pain. Which type of pain is the client experiencing?
A. Perceived pain
B. Somatic pain
C. Peripheral neuropathic pain
D. Peripheral nociceptive pain
C. Peripheral neuropathic pain
Not B or D because somatic pain and peripheral nociceptive pain are both nociceptive pain (pain that results from damage to bones, skin and muscles).
Not A because perceived pain is when the nociceptors are activated enough to send a message to the spinal cord and to the brain.
74
The nurse should assess an Alzheimer’s patient who has been started on rivastigmine for which of the following side effects?
A. Liver toxicity
B. Weight loss
C. Renal failure
D. Extrapyramidal side effects
B. Weight loss
The most common side effects of rivastigmine are flu-like symptoms, dizziness, and weight loss. Rivastigmine is a cholinergic medication.
However, most people choose D. I can see why:
Remember that Alzheimer's is due to a decrease in dopamine in the system. And extrapyramidal side effects are due to the limited quantity of dopamine in the brain. So they must've thought that rivastigmine was a dopaminergic med.
75
This nurse is caring for a client who is receiving prescribed carbamazepine. Which of the following findings would indicate a therapeutic response?
A. Decreased mood lability
B. Steady gait
C. Urinary continence
D. Increased bone mass
A. Decreased mood lability
Carbamazepine is indicated for the prevention of seizures—neuropathic pain. And the treatment of certain mood disorders. The client demonstrating decreased mood lability would be the desired outcome.
Benzodiazepine are downer meds! Used for depression as well. So it makes sense that the answer is A, to regulate mood swings / minimize mood swings.
76
The nurse assesses an infant who sustained a traumatic brain injury (TBI). Which assessment finding requires follow-up?
Select all that apply.
A. Bulging fontanel
B. Tachycardia
C. Bradycardia
D. Ptosis
E. Distended scalp veins
Answer: A, C, E
A tense, bulging fontanel is a classic sign of increased ICP in an infant. Associated symptoms that are concerning include bradycardia and distended scalp veins.
The client would exhibit triad symptoms such as bradycardia, apnea, and widening pulse pressure for ICP.
Ptosis (drooping of eye) is not associated with ICP.
77
The nurse is caring for a patient with a medical diagnosis of scleroderma who reports fingertips tingling and turning white in response to cold or stress. The nurse would recognize these symptoms as which problem?
Raynaud's phenomenon
78
The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure? Select all that apply.
A. Blood pressure
B. End-tidal carbon dioxide [ETCO2] level
C. Respiratory rate
D. Blood glucose
E. Oxygen saturation
Answer: A, B, C, E
Sedation for closed reduction procedures involves placing the bone back in alignment without making incision into skin.
The procedure involves admin of Midazolam, Fentanyl or propofol for moderate sedation.
This is why the nurse must carefully watch the client's vital signs, end-tidal carbon dioxide, and cardiac rhythm during the procedure.
79
A newly registered nurse is caring for a school-aged child with cerebral palsy under the supervision of a senior nurse. Which action by the new RN would warrant the senior nurse to intervene?
A. The new RN initiates gentle range-of-motion exercises to the client.
B. The new RN lowers the bed to its lowest position.
C. The new RN wheels the client to the playroom via wheelchair.
D. The new RN feeds the child with the bed elevated at 30 degrees.
D. The new RN feeds the child with the bed elevated at 30 degrees
Cerebral palsy is a disorder that affects a person's ability to move and maintain balance and posture.
The nurse should position the client with the head of the bed elevated at 60 – 90 degrees to prevent aspiration.
80
When assessing a client who has been ordered skeletal traction, the findings reveal her foot is pale, cold, and her pulse is not palpable. What is the priority nursing intervention?
A. Reassess the foot in twenty minutes
B. Readjust the traction
C. Administer the ordered PRN medication
D. Notify the physician
D. Notify the physician
The symptoms indicate circulatory impairment. The physician (or practitioner) must be notified immediately.
B - Readjusting the traction may help but contacting the physician is the priority
A and C are delaying treatment as a pain med will not resolve circulatory impairment.
81
The nurse is assigned a client with Bell’s palsy. This client’s affected eye does not blink. The nurse’s plan of care should include which of the following?
A. Providing the client an eye patch to be taped to the affected eyelid at all times
B. Instruct the client to keep both eyes closed
C. Evaluate the pupil’s reaction to light and accommodation
D. Obtain a physician’s order for application of eye lubricant
D. Obtain a physician’s order for application of eye lubricant
(Since the client's affected eye is always opened and the eye will get dry)
A - Eye patch should only be taped during client's rest / sleep
B - Client can not close their affected eye
C - Client's pupils are not affected in Bell's palsy, reaction to light should be normal. What's affected is the client's facial motor neurons
82
What is paget's disease?
Paget's disease is a disease caused by a bone becoming weakened and remodelled , which may result in deformities. The most commonly affected areas are the skull, spine, and pelvis.
83
The nurse is caring for a client receiving lorazepam. Which of the following reported herbal supplements would require follow-up?
Select all that apply.
A. Kava
B. Glucosamine
C. Valerian
D. Garlic
E. Saw palmetto
Answer: A, C
Herbal products such as kava and valerian are CNS depressant medications that should not be given concurrently while a client is receiving lorazepam. Lorazepam and one of these medications may cause profound sedation.
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Glucosamine (B) benefit osteoarthritis in the knees, waist, and hips
Garlic (D) reduces cholesterol and should be avoided if the client is taking anticoagulants.
Saw palmetto (E) may be taken for men who have prostate hyperplasia
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84
What is the first assessment the nurse should make when a patient reports he hurt his knee playing baseball and the knee appears swollen?
A. Feel the knee for warmth
B. Compare the swollen knee with the other knee
C. Palpate for crepitus in the knee
D. Assess active range of motion in the knee
B. Compare the swollen knee with the other knee
The first step of assessment is inspection, so the nurse should compare the swollen knee with the other knee.
85
Why is it important to examine the upper outer quadrant of the breast when performing a breast assessment?
A. This is where most breast tumors develop.
B. This part of the breast is more prone to injury and calcifications.
C. This is the largest quadrant of the breast.
D. This is where most of the suspensory ligaments attach.
A. This is where most breast tumors develop.
86
Seizure precautions have been ordered for a patient admitted to the psychiatric unit. Which of the following nursing interventions is not appropriate when initiating seizure precautions? Select all that apply.
A. Pad the side rails of the bed
B. Lower side rails while the patient sleeps
C. Remove hard or sharp objects from the bed
D. Use four point restraints to prevent injury
E. Adhere a fall risk bracelet to the seizure prone patient
Answer: B, D
Lowering the side rails and using four point restraints are not appropriate actions while deploying seizure precautions. Padded bed rails should remain up while the patient sleeps.
Four-point restraints are not appropriate for the seizing patient and could result in injury.
A, C, E are all appropriate precautionary measures for a patient with a hx of seizure.
87
The nurse is caring for a patient with myasthenia gravis who is recovering from a total thymectomy. Which would be the highest priority to have at this patient’s bedside?
A. Crash cart
B. Bag-valve mask
C. Incentive spirometer
D. Atropine sulfate
B. Bag-valve mask
Recent total thymectomy procedure puts this patient at risk for myasthenic crisis (an exacerbation of myasthenia gravis symptoms due to insufficient cholinergic medications) and risk for impaired gas exchange (due to potential hemothorax/pneumothorax).
Noninvasive mechanical ventilation should be used to support respiratory status and improve gas exchange in the event of respiratory distress until other interventions are available.
88
This nurse is caring for a client who is receiving prescribed pregabalin. It will be a therapeutic finding if the client reported less of which of the following?
A. Neuropathic pain
B. Cravings for cigarettes
C. Binge eating
D. Depressive symptoms
A. Neuropathic pain
Think pregabalin = gaba neurotransmitter --> inhibits CNS in the brain = gabapentin --> for neuropathic pain
89
The RN provides teaching to a patient with epilepsy who has just been started on carbamazepine to control seizure activity. Which information would be important for the nurse to include regarding this medication?
A. Take this medication with 8 ounces of water or juice.
B. Avoid taking this medication on an empty stomach
C. Discontinue immediately if any vision changes occur.
D. Avoid strenuous activity if drowsiness occurs.
B. Avoid taking this medication on an empty stomach
The nurse should instruct this patient that carbamazepine should be taken with meals. The patient should avoid taking this medication on an empty stomach in order to reduce the risk of experiencing side effects.
Carbamazepine is a anticonvulsant, NOT a benzodiazepine.
90
Tizanidine - what is it? What does it treat?
Tizanidine is a muscle relaxant. Used to treat multiple sclerosis (due to damaged nerves from antibodies --> Causing muscle spasms)
91
The nurse is taking care of a client that is status-post hand arthroplasty. The nurse should not include which nursing action to prevent complications?
A. Encourage the client to exercise his fingers 10 times every hour, attempting full range of flexion and extension.
B. Place the client’s personal items within easy reach of the non-operative arm.
C. Place the client’s operative arm on a pillow to rest and keep it elevated.
D. Encourage the client to use the non-operative arm as much as possible.
C. Place the client’s operative arm on a pillow to rest and keep it elevated.
Placing the client’s operative arm on a pillow produces pressure on the ulnar nerve. This should not be included in the client’s care plan. The nurse should place the hand in a sling and suspend it from the bed.
A - Finger exercises reduce edema and pain. This intervention should be included and must be implemented.
B and D - encouraging use to non-operative arm promotes independence
92
A patient has been on bed rest for a week after a fractured left hip. Which of the following symptoms, if noted in the patient, would be considered signs of complications due to immobility? Select all that apply.
A. An area of the patient’s sacrum is unable to be blanched.
B. The skin has a faint yellow tinge.
C. Crackles in the bases of the patient’s lungs.
D. Pain, swelling, and tenderness in the left calf.
E. Using the bedpan to void.
F. The patient’s blood sugar is 79.
Answer: A, C, D
A patient who has been on bedrest will begin to experience complications such as atelectasis (collapse of lung), bedsores, and DVTs unless attended to by nursing staff.
93
The nurse should provide which instruction on how to prevent botulism in infants?
1. Boil water if unsure of is source
2. Discard canned food with a bulging end
3. Keep milk cold
4. Wash hands
2. Discard canned food with a bulging end
Botulism is caused by the gastrointestinal absorption of the neurotoxin produced by Clostridium botulinum. The neurotoxin blocks acetylcholine at the neuromuscular junction, resulting in muscle paralysis.
The main source of botulism is improperly canned or stored food. A metal can's swollen/bulging end can be caused by the gases from C botulinum and should be discarded.
94
A nasogastric tube has been inserted into a client with bowel obstruction for gastric decompression. The nurse should set the suction on which setting?
A. Intermittent suction at 70 mmHg
B. Intermittent suction at 100 mmHg
C. Continuous suction at 100 mmHg
D. Continuous suction at 70 mmHg
A. Intermittent suction at 70 mmHg
Continuous suction and suction pressure > 80 mmHg will cause gastric mucosa to injury and ulceration.
95
The nurse is caring for a patient diagnosed with epilepsy. The nurse should anticipate a prescription for which of the following medications? Select all that apply.
A. Topiramate
B. Risperidone
C. Prazosin
D. Hydroxyzine
E. Lorazepam
Answer: A, E
Topiramate - think TOP = brain = treats seizure and prevents migraine.
Lorazepam - It's a benzodiazepine - used to treat acute seizures
96
The nurse is caring for a client experiencing an episode of vertigo. The nurse should plan to take which essential action?
A. Avoid sudden movement changes
B. Provide additional pillows to support the client's head
C. Raise the upper side rails of the bed
D. Instruct the client to move the head slowly
C. Raise the upper side rails of the bed
When looking at this question, think: A client is experiencing vertigo, an essential action would be to provide SAFETY for the client.
Raising the upper side rails of the bed is a safety measure.
A, B, D are all interventions for vertigo, but C is the priority.
97
The nurse is caring for a client that underwent a total knee arthroplasty the previous day. The nurse will include which intervention in the patient’s care plan?
A. Place the client on a continuous passive motion exerciser for 6-8 hours a day.
B. Ask the client to dangle his feet on the bed for 5 minutes before standing up.
C. Encourage weight bearing on the affected knee joint.
D. Instruct the client to maintain a flexed knee while in bed.
A. Place the client on a continuous passive motion exerciser for 6-8 hours a day.
The client is placed on a continuous passive motion exerciser for a minimum of 6-8 hours a day. This ensures that the knee is having its maximal range of motion, which is the goal for rehabilitation.
Dangling is avoided to prevent dislocation
Weight bearing on affected foot is avoided until deemed by physician
Flexion on bed is avoided to prevent contractures.
98
An elderly client has just finished a total knee replacement surgery. The nurse suspects fluid overload in the client. Which of the following signs and symptoms would confirm the nurse’s suspicion?
A. Blood pressure of 90/55 mmHg; weak, thready pulse; slightly elevated temperature.
B. Cool, clammy skin; bounding pulse; cough.
C. Headache, Lethargy, and abdominal pain.
D. Fever; warmth, swelling, and redness at the operative site.
B. Cool, clammy skin; bounding pulse; cough.
Cool and clammy skin, bounding pulses, productive cough, distended neck veins, edema, and polyuria are signs of fluid overload.
99
The nurse is caring for a client with an acute migraine headache. The nurse would anticipate a prescription for which medication? Select all that apply.
A. Ketorolac
B. Nitroglycerin
C. Topiramate
D. Dexamethasone
E. Hydromorphone
F. Acetaminophen-caffeine
Answer: A, D, F
Treatment for an acute migraine headache (MH) involves abortive medications such as ketorolac (NSAID), dexamethasone (corticosteroid), and acetaminophen-caffeine. Depending on the severity of the MH, the provider takes a stepwise or aggressive approach to treatment.
100
The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following?
A. Atonic seizure
B. Tonic-clonic seizure
C. Absence seizure
D. Complex partial seizure
A. Atonic seizure
Atonic seizures are drop attacks or drop seizures that cause a sudden loss of muscle tone and result in the client collapsing. This is quite serious as this may cause a client to sustain an injury.
101
The nurse is evaluating the progress of a completely paraplegic female client with a C6-C7 spinal cord injury. Which indicator signifies that the client is improving in physical therapy?
A. The client can control the motorized wheelchair.
B. The client states she wants to stand up with assistance.
C. The client says she wants to move her toes.
D. The client says she regained her bladder control.
A. The client can control the motorized wheelchair.
A C6-C7 spinal cord injury (SCI) can still retain some ability to extend shoulder, arms, and fingers with compromised dexterity in the hands and fingers.
Rehabilitation often will focus on learning to use the non-paralyzed portions of the body to regain varying levels of autonomy.
102
The patient is prescribed a bisphosphonate to treat osteoporosis. Which information should the nurse inform this patient about?
A. Take this medication sitting upright first thing in the morning with a full glass of water.
B. Take this medication at night, just before bed.
C. This medication should be taken along with a full meal.
D. This medication is the best alternative if an esophageal disorder is present.
A. Take this medication sitting upright first thing in the morning with a full glass of water.
Bisphosphonates should be taken first thing in the morning with a full glass of water. Patients should also wait 30 minutes to eat any food and should remain sitting or standing during that time. This prevents esophageal damage that may occur when this medication is taken improperly.
Med not taken before night time or with meals.
Need to stay up for at least 30 mins, and no meals to increase drug effectiveness
Bisophosphates are contraindicated for esophageal disorder pts.
103
Which of the following should not be taken with phenytoin?
A. Acetaminophen
B. Ibuprofen
C. Calcium carbonate
D. Ranitidine
C. Calcium carbonate
Calcium carbonate, or Tums (Antacids) should not be taken with ANY medications! Just like how grape juice should not be taken with any medications.
104
Which of the following is an appropriate outcome for a client who is adversely affected with an impairment of their 2nd cranial nerve?
A. The client will not experience sensory overload in the hospital.
B. The client will list ways to effectively decrease their blood pressure.
C. The client will participate in physical therapy to improve balance.
D. The client will remain free of falls despite 2nd cranial nerve impairment.
D. The client will remain free of falls despite 2nd cranial nerve impairment.
The second cranial nerve is the optical nerve. Clients with the second cranial nerve affected will have trouble seeing. This puts them on a higher risk of falls.
105
Macewen's sign - What is it? What does it tell us?
Macewen's sign is used to detect hydrocephalus. Percussion on the skull at the frontal, temporal and parietal bones junction --> Auscultate a cracked pot or hyper-resonant sound if hydrocephalus is present.
106
The nurse is conducting patient teaching to a client with a level T4 spinal cord injury to transfer from the bed to the wheelchair independently. The nurse should emphasize to the client to move:
A. His upper and lower body should move together into the wheelchair.
B. His upper body moves into the wheelchair first.
C. His lower body into the wheelchair first, placing his feet on the pedals, and then his hands to the wheelchair arms.
D. His buttocks to the wheelchair first and then place his feet to the floor.
B. His upper body moves into the wheelchair first.
When transferring a patient with paralysis of the lower extremities from a bed to a wheelchair, move the big part of the body (upper) to the chair first. This is the proper technique and the safest. The client should move his upper body to the wheelchair first, then his legs from the bed to the wheelchair.
107
The nurse is caring for a client who sustained an ischemic cerebrovascular accident (CVA) three hours ago. The client's most recent blood pressure was 168/101 mm Hg. The nurse should take which action?
A. Place the client supine
B. Continue to monitor
C. Obtain orthostatic blood pressure
D. Request a prescription for an antihypertensive
B. Continue to monitor
Maintaining the BP below 185/110 mm Hg and above 150/100 mm Hg is needed to maintain cerebral perfusion after an acute ischemic stroke.
This enables perfusion around the stroke to distal tissue.
108
When a client with mid-stage Alzheimer's disease becomes agitated, which intervention should the nurse use?
A. Placing an arm around the client's shoulders
B. Turning on the television
C. Place the client in a darkened room
D. Encourage the client to join a group activity
A. Placing an arm around the client's shoulders
Nursing interventions for Alzheimer's patients with "agitation" include providing a safe environment free of external stimulation and offering calming emotional support.
Placing an around the client's shoulders is therapeutic touch. Doing so is comforting and provides reassurance to an agitated patient.
109
The nurse is caring for a client newly prescribed ropinirole. The nurse understands that this medication is prescribed to treat which condition?
A. Multiple Sclerosis
B. Parkinson disease
C. Schizophrenia
D. Guillain-barré syndrome
B. Parkinson disease
Ropinirole is a dopaminergic drug used in conjunction with other medications to treat Parkinson's disease.
Think ropinirole is treating => pill rolling (symptom of parkinsons)
110
Which of the following are signs of brainstem involvement in a pediatric patient with a neurologic injury?
Select all that apply.
A. Dilated pupils
B. Narrowing pulse pressure
C. Bradycardia
D. Tachypnea
Answer: A, C
The keyword is brainstem, the brainstem controls the body's HR, and respiratory functions.
Widening pulse pressure (Big difference in BP), bradycardia, pupils sluggish/dilated/ unequal are signs of brainstem involvement are all signs of brain stem injury.
111
Cushing's triad: What are the symptoms, what does it indicate?
Widening pulse pressure (Big difference in BP)
Bradycardia
Irregular respirations
It indicates increased intracranial pressure (ICP)
112
What does the nurse have to monitor after the placement of this epidural catheter and the initiation of an opioid epidural infusion?
Since it is opioid, the nurse has to monitor the signs of respiratory depression and level of sedation. EVERY hour for the first 24 hours!
