Glasgow Coma Scale. Which of the following indicators will be used to determine the score? a.Eye opening, and appropriateness of verbal ad motor responses. b.Ability to recall recent and remote memories and to use abstract reasoning. c.Assessment of the 12 cranial nerves d.Naming of objects, recall of three words, and ability to redraw a design. 2.The clients daughter asks the nurse why the nurse is asking her mother depressionrelated questions. The nurse explains that even though the client has symptoms of dementia , the Geriatric Depression Scale is being used because a.Depression and dementia are one in the same disorder b.Finding out why she is depressed will help determine the cause of her dementia c.Depression often mimics s/sx of dementia d.It is the most accurate tool to determine stage of dementia 3.The nurse documents findings from the clients responses to the SLUMS test. The following information will be documented as a result of this test. a.Mood, feelings, expressions ad perceptions b.Orientation, memory, speech and cognitive function c.Energy level, satisfaction and social participation d.Appropriateness of dress, grooming and eye contact 4. As part of assessing the clients LOC, the nurse asks questions related to person, place and time. Which of these statements is true? a.Orientation to person is usually lost first and orientation of time is lost last. b.Orientation to time is usually lost first and orientation to person usually lost last c.Orientation to person is usually lost first and orientation to place is lost last d.Orientation to time is usually lost first and orientation to place is usually ost last. 5. When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is tested? a.Judgement c. concentration b.Memory to learn new info d. abstract reasoning
6. Sensations of temperature, pain and crude
and light touch are carried by way of the a. Extrapyramidal tract c. Spinothalamic tract b. Corticospinal tract d. Posterior tract 7. The cranial nerve that has sensory fibers for taste and fibers that result in the gag reflex is the: a. Vagus c. hypoglossal b. Trigeminal d. glossopharyngeal 8. The nurse is assessing an older adult client when the client tells the nurse that she has experienced transient blind spots for the last few days. The nurse should refer the client t a physician for possible: a.vagus nerve damage c. spinal cord compression b. stroke d. Parkinson disease 9. The nurse is planning a presentation to a group of adults on the topic of strokes. Which of the following should the nurse plan to include in the teaching plan? a. Strokes are the number one cause of death in the US b. Smoking and high cholesterol levels are risk factors of stroke c. Clients who smoke while taking oral contraceptives are not at higher risk d. Postmenopausal women taking estrogen are at greater risk for stroke 10.The nurse is caring for a client dring the intermediate postop period after abdominal surgery. While performing a neuro check the nurse should assess te clients a.Sensation in the extremities c. ability to speak b. Deep tendon reflexes d. recent memory 11. The nurse si preparing to percuss a clients reflexes in his arms To use the reinforcement technique the nurse should ask the client to: a. Clench his jaw b. Stretch the opposite arm c. hold his neck toward the floor d. straighten his legs forward 12. Which cranial nerve is the nurse testing when the client is asked to identify a scented object? a.Oculomotor c. optic
b.Facial
d. olfactory
13.Reduced ability to sense vibrations of a
tuning fork may be present with a.Peripheral neuropathy c. graphesthesia b. Nystagmus d. stereognosis 14. While assessing the neurologic system of a confused older adult, the nurse observes that the client is unable to recall past events. The nurse suspects that te client may be exhibiting signs of: a. Depression c. attention deficit disorder b. Anxiety d. cerebral cortex disorder 15. The nurse is assessing the neurologic system of an adult client. To test the clients recent memory, the nurse should ask the client a. What did you have for breakfast? b. How old were you when you began working? c. Who is the 44th president of the US? d. Can you recall the name of your firstgrade teacher? 16. Which of the ff are examples of a nosocomial infection that can occur in a health care facility? SATA 1. a common cold that develops in a pt 2. sepsis that results from contaminated IV fluids 3. a UTI that develops after catheter insertion 4. a streptococci wound infection that develops in a post-op pt 5.the development of clostridium tetani in immunospressed pt 6. a respiratory infection that develops in a pt receiving frequent respiratory treatment and requires frequent suctioning a. 2,3,4,5 b. 2,4,5,6
c. 1,2,3,4,5 d. 2,3,4,5,6
Situation: A pt is brought to the hospital
after vomiting bright red blood and is admitted through the ER with bleeding duodenal ulcer 17. While the pt is bleeding, it will be essential for the nurse to assess frequently for s/s of shock. Which of the ff indicator of early signs of shock? a. tachycardia c.urine output b. dry flushed skin d. loss of consciousness
18. If the pt develops sudden sharp pain in
the mid-epigastric region along with the rigid, board-like abdomen, the nurse should understand that these clinical manifestations most likely indicate that: a. an intestinal obstruction has developed b. additional ulcers have developed c. the esophagus has become inflamed d. the ulcer has perforated 19. The spouse of a client with an intracranial hemorrhage asks the nurse, "Why aren't they administering an anticoagulant?" How should the nurse respond? a. "It is contraindicated because bleeding will increase." b."If necessary it will be started to enhance circulation." c."If necessary it will be stated to prevent pulmonary thrombosis." d."It is inadvisable because it masks the effects of the hemorrhage." A. "It is contraindicated because bleeding will increase." Rationale: An anticoagulant should not be administered to a client who is bleeding because it will interfere with clotting and will increase hemorrhage. Anticoagulants are unsafe and will not be used to enhance the circulation or prevent pulmonary thrombosis. The response "It is inadvisable because it masks the effects of the hemorrhage" is not the reason why it is contraindicated; if given, it will increase, not mask, the effects of the hemorrhage. 20. Initially after a brain attack (cerebrovascular accident), a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing? A. Spinal shock C. Transtentorial herniation B. Hypovolemic shock D. intracranial pressure 21. A client is admitted to the hospital with weakness in the right extremities and a slight difficulty with speech. Vital signs are within expected limits. What is the priority nursing action during the first 24 hours? a.Taking the client's temperature. b.Evaluating the client's motor status.
c.Obtaining the client's urine for a urinalysis.
d.Monitoring the client's BP for hypertension. B. Evaluating status.
the
client's
motor
Rationale: Evaluating the client's motor
status will indicate whether symptoms progress or improve and assist the health care provider in determining the diagnosis. An elevation in temperature is not an early sign of an extension of a brain attack (cerebrovascular accident [CVA]). Obtaining a urine specimen for a urinalysis is not the priority. The data indicate that vital signs are within expected limits and do not reflect hypertension; although the vital signs should be monitored, the client's motor status in this instance is most significant. 23. Which clinical indicator does a nurse identify when assessing a client with hemiplegia? a.Paresis of both lower extremities b.Paralysis of one side of the body c.Paralysis of both lower extremities d.Paresis of upper and lower extremities 24. The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure? a. Polyuria c. Tachypnea b. Increased restlessness d. Intermittent tachycardia 25. A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client? a.Monitor vital signs. b.Maintain an open airway. c.Monitor pupil response and equality. d.Maintain fluid and electrolyte balance 26. A client receiving morphine is being monitored by the nurse for signs and symptoms of overdose. Which clinical findings support a conclusion of overdose? (Select all that apply.) a.Polyuria c. Lethargy c. Bradycardia d. Dilated pupils e. Slow respirations 27. A client arrives on the nursing unit unconscious and exhibiting decerebrate
posturing. When assessing the client, the
nurse expects to observe: a.Hyperextension of both the upper and lower extremities b.Spastic paralysis of both the upper and lower extremities c.Hyperflexion of the upper extremities and hyperextension of the lower extremities d. Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities Rationale: A. Limbs hyperextended and arms hyperpronated (extension posturing, decerebrate posturing) indicate upper brainstem damage; this is a grave sign. Spastic paralysis of both the upper and lower extremities is associated with an upper motor neuron disease or lesion. Hyperflexion of the upper extremities and hyperextension of the lower extremities is associated with flexion posturing (decorticate posturing), which indicates damage to the pyramidal motor tract above the brainstem. Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities is associated with a lower motor neuron disease or lesion. 28. A client arrives at the nursing unit with neurological deficits after a motor vehicle accident. Using the Glasgow Coma Scale, the nurse assesses what client responses? (Select all that apply.) a. Pupil response to light b. Verbal response to speech c. Eye opening in response to speech d. Deep tendon reflexes in response to percussion e. Motor activity in response to a verbal command 29. nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern a. Flexing c. Localizing b.Extending d.Withdrawing 30. A health care provider prescribes mannitol (Osmitrol) for a client with a head injury. The nurse concludes that the purpose of the medication is to relieve cerebral edema by: a. Decreasing the production of cerebrospinal fluid
b. Limiting the metabolic requirements of the
brain c. Drawing fluid from brain cells into the bloodstream d. Preventing uncontrolled electrical discharges in the brain Rationale: Mannitol, an osmotic diuretic, pulls fluid from the white cells of the brain to relieve cerebral edema. Preventing uncontrolled electrical discharges in the brain is the action of phenytoin sodium (Dilantin), not mannitol. 31. A client has a brain attack (cerebrovascular accident [CVA]) that involves the right cerebral cortex and cranial nerves. What areas of paralysis should the nurse expect the client to exhibit? (Select all that apply.) a. Left leg c.Left arm b. Right leg d. Right arm e. Left side of face
Kwawu Foster Kwesi - Breast Cancer, Knowledge, Attitudes and Perception Amongs Female Soldiers of The Ghana Armed Forces in The Greater Accra Region - 2009 PDF