1. An important consideration in the elderly population is: potential for drug-nutrient interaction related to polypharmacy.
2. A nurse is teaching a
... [Show More] client with a left leg weakness to walk with a cane. The nurse should include which nursing points about safe cane use in the client teaching? (Select all that apply)
• Hold the cane on the uninvolved side of the body.
• Adjust the cane so that the handle is level with the hip bone.
• Avoid leaning on the cane to get in and out of a chair.
3. Match Nerve with Motor ability in spinal cord patient.
*Respiratory Issues= C1-3 *Able to have elbow flexion= C 5 *Propel a wheelchair using nobs= C7- 8
*Hip flexion= L2
5. A nurse is planning care for a patient with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care?
Maintain respiratory isolation precautions.
6. A nurse is collaborating with the interdisciplinary team to help manage a patient's recurrent headaches. What aspect of the patient's health history should the nurse identify as a potential contributor to the patient's headaches?
The patient takes vasodilators for the treatment of angina.
7. The nurse is caring for a patient with head injury. Place the following in priority - starting with the nursing assessment the nurse should perform first.
I. Level of consciousness II. Motor strength III. Vital signs IV. decreased urine output
8. The nurse anticipates that patients with bacterial meningococcal meningitis may commonly exhibit which of the following findings?
Petechiae
9. The nurse responds to a call bell. When she arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action?
Assist the patient to the floor and provide soft head support.
10. Which actions should you delegate to UAP when caring for a patient with a thrombotic stoke who has residual left- sided weakness? Select all that apply
• Setting up meal trays and assisting with feeding.
• Assisting patient to reposition every 2 hours.
• Reapplying pneumatic compression boots..
• Reminding the patient to perform active ROM exercises.
11. A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? 70
12. A risk factor associated with bacterial meningitis is living in a dormitory.
13. Cluster headaches can occur and reoccur several times a day for several weeks: TRUE
14. Tension type headaches may occur with or between migraine headaches: TRUE
15. A patient is brought to the ER with possible stroke. What initial diagnostic test for a stroke would the nurse prepare patient for?
CAT scan
16. A 29-year-old post-partum woman relates that she has had recent headaches only when standing up. The headaches resolve quickly when she lies down and are accompanied by mild nausea. Her examination is normal, but she reports having had epidural anesthesia during childbirth. What do you think is happening?
intracranial hypotension
17. A patient has a diagnosis of expressive (motor, non-fluent) aphasia. In evaluating the patient's ability to verbally communicate, it would be most appropriate for the nurse to ask which of the following?
"What was your mother's maiden name?"
18. A patient has been admitted to the critical care unit after a stroke. She has “failed” her swallowing study and is placed on enteral feedings. The nurse has just placed a nasogastric feeding tube. What is the next step?
Obtain a chest x-ray
19. A nurse is caring for a patient who experiences debilitating cluster headaches. The patient should be taught to take appropriate medications at what point in the course of the onset of a new headache?
As soon as the patient senses the onset of symptoms
20. Match the items in the alphabetic list to the numbered items.
Receptive aphasia= Unable to comprehend the spoken word Dysphagia= Difficulty in swallowing Hemianopsia= Visual difficulties Hemiplegia= One side of body is paralyzed
21. A nurse is planning care for a patient who experienced a stroke in the right hemisphere of his brain. What should the nurse do?
Provide close supervision because of the patient's impulsiveness and poor judgment.
22. A 63-year-old man presents to the ER with a right hemiparesis and a nonaffluent aphasia that began 45 minutes ago. blood pressure is 160/80, coagulation studies are normal, and there is no recent history of bleeding. A head CT scan shows no evidence of intracranial hemorrhage. Which of the following is the most appropriate therapy at this point?
IV TPA
23. The nurse is caring for a patient scheduled to undergo a lumbar puncture. Which statement, if made by the patient, would indicate to the nurse that the patient needed more pre-procedural teaching? "I will have to:
Restrict my fluid intake for several hours before and after the procedure." [Show Less]