front 1 A nurse is teaching a client with a cerebellar function impairment which statement would the nurse include in this client's discharge teaching? | back 1 Ask a friend to drive you to your follow up appointments |
front 2 The nurse is performing an assessment of cranial nerve III which testing is appropriate | back 2 Pupil constriction |
front 3 During a lumbar puncture which position should the patient be in | back 3 Pt should be on the left side knees to chest( fetal position) |
front 4 An 84 year old client who is usually alert and oriented experiences an acute cognitive decline which of the following factors would the nurse anticipate as contributing to this neurologic change(SATA) | back 4 Infection Drug toxicity Hypoxia |
front 5 The nurse is teaching the daughter of a client who has middle stage alzheimer disease the daughter asks will the sertraline my mother is taking improver her dementia how would the nurse respond about the purpose of the drug | back 5 It will not improve her dementia but can help control emotional responses |
front 6 A client with early stage alzheimer disease is admitted to the hospital with chest pain which nursing action is most appropriate to manage this clients dementia | back 6 Ensure a structured and consistent environment |
front 7 The nurse observes a client with late stage alzheimer disease eat breakfast afterward the client states I am hungry and want breakfast what is the nurse's best response | back 7 I see you are still hungry I will get you some toast |
front 8 The nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed alzheimer disease which statement by the caregiver indicates a need for further teaching | back 8 I will avoid communicating with the client to prevent agitation |
front 9 The nurse teaches assistive personnel (AP) about how to care for a client with early stage alzheimer disease which statement would the nurse include | back 9 Reorient the client to the day time and environment with each contact |
front 10 After teaching the wife of a client who has parkinson disease the nurse assesses the wifes understanding which statement by the clients wife indicates that she correctly understands changes with this disease | back 10 He may have trouble chewing so I will offer bite sized portions |
front 11 The nurse plans care for a client with parkinson disease which intervention would the nurse include in this client's plan of care | back 11 Keep the head of the bed at 30 degrees or greater |
front 12 A nurse teaches assistive personnel(AP) about how to care for a client with parkinson disease which statement would the nurse include as part of this teaching | back 12 Allow the client to be as independent as possible with activities |
front 13 A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis which question would the nurse ask | back 13 Do you live in a crowded residence |
front 14 The nurse plans care for a client with epilepsy who is admitted to the hospital which interventions would the nurse include in this client's plan of care (SATA) | back 14 Have suction equipment with an airway at the bedside Have oxygen administration set at the bedside Ensure that the client has IV access |
front 15 The nurse assesses a client who has parkinson disease which signs and symptoms would the nurse recognize as a key feature of this disease(SATA) | back 15 Flexed trunk Slow movements Uncontrolled drooling |
front 16 The nurse initiates care for a client with a cervical spine cord injury who arrives via emergency medical services what action would the nurse take first | back 16 Evaluate respiratory status |
front 17 A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury what other assessment finding will the nurse anticipate for this client | back 17 Flaccid bowel |
front 18 The nurse is performing a focused assessment of left posterior temporal lobe functions will assess the patient for | back 18 Ability to understand written and oral language |
front 19 Which problem can the nurse expect for a patient who has a positive romberg test result | back 19 Falls |
front 20 A nurse assesses a client who is recovering from anterior cervical discectomy and fusion which complications should alert the nurse to urgently communicate with the healthcare provider | back 20 Auscultated stridor |
front 21 A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program the client states I don't understand the need for rehabilitation the paralysis will not go away and it will not get better how would the nurse respond | back 21 "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." |
front 22 After teaching a client with a high thoracic spinal cord injury the nurse assesses the client's understanding which statement by the client indicates a correct understanding of how to prevent respiratory problems at home | back 22 I’ll use my incentive spirometer every 2 hours while i'm awake |
front 23 A client is scheduled for a percutaneous endoscopic lumbar discectomy which statement by the client indicates a need for further teaching | back 23 I'll be in the hospital for 2 to 3 days |
front 24 A nurse assess clients at a community center which client is at greatest risk for low back pain | back 24 A 45-year-old male with osteoarthritis |
front 25 A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion which complications would the nurse report to the primary healthcare (SATA) | back 25 Incisional bulging Clear drainage on the dressing Sudden and severe headache |
front 26 A nurse assess a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum what actions would the nurse take (SATA) | back 26 Reposition the client off the reddened areas Apply a pressure reducing mattress |
front 27 A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago which assessment findings would the nurse correlate with neurogenic shock (SATA) | back 27 Heart rate of 34 beats/min Urine output less than 30 mL/hr Decreased level of consciousness |
front 28 A nurse assesses a client who is recovering from an open traditional anterior cervical fusion which assessment findings would alert the nurse to a complication from this procedure (SATA) | back 28 Difficulty swallowing Hoarse voice |
front 29 A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide(Cytoxan) and methylprednisolone(Medrol)which statement should the nurse include in this clients discharge teaching | back 29 "Avoid crowds and people with colds." |
front 30 A nurse cares for a client who has been diagnosed with huntington gene but has no symptoms the client ask for options related to family planning what is the nurses best respond | back 30 Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider. |
front 31 An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash which planned intervention by the healthcare provider should the nurse question | back 31 Prepare the patient for lumbar puncture |
front 32 During the neurological assessment the patient is unable to respond verbally to the nurse but cooperates with the nurse's direction to move his hands and feet. What should the suspect as a likely cause of these findings? | back 32 damage to the frontal lobe. |
front 33 The nurse recognizes which pathophysiologic feature as a hallmark of guillain barre syndrome | back 33 The immune system destroys the myelin sheath. |
front 34 A patient who has numbness and weakness of both feet is hospitalized with Guillain barre syndrome the nurse will anticipate that collaborative interventions at this time will include | back 34 IV infusion of immunoglobulin (Sandoglobulin). |
front 35 The nurse advises a patient with myasthenia gravis (MG) to | back 35 Perform physically demanding activities early in the day |
front 36 A patient who has amyotrophic lateral sclerosis(ALS) is hospitalized with pneumonia which nursing action will be included in the plan of care | back 36 Assist with active range of motion |
front 37 A 40 year old patient is diagnosed with early huntington's disease(HD) when teaching the patient the spouse and adult children about this disorder the nurse will provide information about the | back 37 Option of genetic testing for the patients children to determine their own HD risk |
front 38 When a 74 year old patient seen in the health clinic the new development of a stooped posture shuffling gait and pill rolling type tremor the nurse will anticipate teaching the patient about | back 38 Antiparkinsonism drugs |
front 39 A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit which equipment should the nurse have available in the patients assigned room(SATA) | back 39 Side rail pads Suction tubing Oxygen mask |
front 40 A patient with parkinson's disease is admitted to the hospital for treatment of pneumonia which nursing interventions will be included in the plan of care(SATA) | back 40 Provide an elevated toilet seat Cuts patients food into small pieces Place an armchair at the patient's bedside |
front 41 A patient with bell's palsy refuses to eat while others are present because of embarrassment about drooling the best response by the nurse is to | back 41 Respect the patient's feelings and arrange for privacy at mealtimes |
front 42 A patient hospitalized with a new diagnosis of Guillain Barre syndrome has numbness and weakness of both feet the nurse will anticipate teaching the patient about | back 42 Infusion of immunoglobulin |
front 43 A patient is hospitalized with a new onset of Guillain barre syndrome the most essential assessment for the nurse to complete is | back 43 Observing respiratory rate and effort |
front 44 You suspect bell's palsy in which patient | back 44 Sudden onset one sided facial weakness with ear pain and vesicles |
front 45 A nurse plans care for a 77 year old client who is experiencing age related peripheral sensory perception changes which intervention would the nurse include in the client's plan of care . | back 45 Ensure that the path to the bathroom is free from clutter. |
front 46 When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about health problems and health history primarily to | back 46 assess the patient's baseline cognitive abilities |
front 47 When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include? | back 47 "You should call the doctor if pain or herpes lesions occur near the ear." |
front 48 What action should the nurse incorporate when administering a mental status examination to a patient with delirium | back 48 Choose a place without distracting stimuli |
front 49 A patient is diagnosed with moderate dementia after multiple strokes. What would the nurse expect to find during assessment of the patient? | back 49 Loss of recent long and term memory |
front 50 While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? | back 50 Time and observe and record the details of the seizure and postictal state |
front 51 A nurse teaches a client who is recovering from an open traditional cervical spine fusion which statement would the nurse include in this clients post operative instructions | back 51 Wear your neck brace whenever you are out of bed |
front 52 A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care? | back 52 Instruct the patient how to self catheterize |
front 53 the nurse is caring for a patient who is being evaluated for a possible metastic spinal cord which of these data obtained when assessing the patient requires most immediate action by the nurse | back 53 the patient has new onset weakness in both legs |
front 54 a patient with a history of a T2 spinal cord tells the nurse i feel awful today my head is throbbing and i feel sick to my stomach which action should the nurse take first | back 54 check the blood pressure |