Nursing 121 exam 3 || Already Graded A+.
When admitting an acutely confused patient with a head injury, which action should the nurse
take?
a. Ask family members about the patient's health history.
b. Ask leading questions to assist in obtaining health data.
c. Wait until the patient is better oriented to ask questions.
d. Obtain only the physiologic neurologic assessment data. correct answers A
When admitting a patient who is likely to be a poor historian, the nurse should obtain health
history information from others who have knowledge about the patient's health. Waiting until
the patient is oriented or obtaining only physiologic data will result in incomplete assessment
data, which could adversely affect decision making about treatment. Asking leading questions
may result in inaccurate or incomplete information.
Which finding would the nurse expect when assessing the legs of a patient who has a lower
motor neuron lesion?
a. Spasticity c. Impaired sensation
b. Flaccidity d. Hyperactive reflexes correct answers B
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the
neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive
reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor
neuron lesions.
The nurse performing a focused assessment of left posterior temporal lobe functions will
assess the patient for
a. sensation on the left side of the body.
b. reasoning and problem-solving ability.
c. ability to understand written and oral language.
d. voluntary movements on the right side of the body. correct answers C
The posterior temporal lobe integrates the visual and auditory input for language
comprehension. Reasoning and problem solving are functions of the anterior frontal lobe.
Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary
movement on the right side is controlled in the left precentral gyrus.
4. Propranolol (Inderal), a -adrenergic blocker that inhibits sympathetic nervous system
activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse
monitors the patient for
a. dry mouth. c. constipation.
b. bradycardia. d. urinary retention. correct answers B
Inhibition of the fight-or-flight response leads to a decreased heart rate. Dry mouth,
constipation, and urinary retention are associated with peripheral nervous system blockade.
5. To assess the functions of the trigeminal and facial nerves (CNs V and VII), the nurse should
a. check for unilateral eyelid droop.
b. shine a light into the patient's pupil.
c. touch a cotton wisp strand to the cornea.
,d. have the patient read a magazine or book. correct answers C
The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is
tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response
to light and ptosis are used to evaluate function of the oculomotor nerve.
Which action will the nurse include in the plan of care for a patient with impaired functioning
of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?
a. Assist to stand and ambulate. c. Insert an oropharyngeal airway.
b. Withhold oral fluids and food. d. Apply artificial tears every hour. correct answers B
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A
patient with impaired function of these nerves is at risk for aspiration. An oral airway may be
needed when a patient is unconscious and unable to maintain the airway, but it will not
decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. Balance and
coordination are cerebellar functions.
An unconscious male patient has just arrived in the emergency department with a head injury
caused by a motorcycle crash. Which order should the nurse question?
a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c. Send for computed tomography (CT) scan.
d. Perform neurologic checks every 15 minutes. correct answers B
After a head injury, the patient may be experiencing intracranial bleeding and increased
intracranial pressure, and herniation of the brain could result if lumbar puncture is performed.
The other orders are appropriate.
. After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no
residual effects, the nurse anticipates teaching the patient about
a. cerebral aneurysm clipping. c. oral low-dose aspirin therapy.
b. heparin intravenous infusion. d. tissue plasminogen activator (tPA). correct answers C
The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that
inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin
infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms
are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not
for TIA.
A patient is being admitted with a possible stroke. Which information from the assessment
indicates that the nurse should consult with the health care provider before giving the
prescribed aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient reports that symptoms began with a severe headache.
d. The patient has a history of brief episodes of right-sided hemiplegia. correct answers C
A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is
contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack are not
contraindications to aspirin use.
,A patient with a stroke experiences facial drooping on the right side and right-sided arm and
leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to
find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions correct answers D
Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with
comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive
behavior and neglect are more likely with a right-side stroke.
During the change of shift report, a nurse is told that a patient has an occluded left posterior
cerebral artery. The nurse will anticipate that the patient may have
a. dysphasia. c. visual deficits.
b. confusion. d. poor judgment. correct answers C
Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with
middle cerebral artery involvement. Cognitive deficits and changes in judgment are more
typical of anterior cerebral artery occlusion.
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral
atherosclerosis
a. to monitor and record the blood pressure daily.
b. to call the health care provider if stools are tarry.
c. that clopidogrel will dissolve clots in the cerebral arteries.
d. that clopidogrel will reduce cerebral artery plaque formation. correct answers B
Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, so
patients should be advised to notify the health care provider about any signs of bleeding. The
medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy.
Which response by the nurse is accurate?
a. "The obstructing plaque is surgically removed from inside an artery in the neck."
b. "The diseased portion of the artery in the brain is replaced with a synthetic graft."
c. "A wire is threaded through an artery in the leg to the clots in the carotid artery,
and the clots are removed."
d. "A catheter with a deflated balloon is positioned at the narrow area, and the
balloon is inflated to flatten the plaque." correct answers A
In a carotid endarterectomy, the carotid artery is incised, and the plaque is removed. The
response beginning, "The diseased portion of the artery in the brain is replaced" describes an
arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is
positioned at the narrow area" describes an angioplasty. The final response beginning, "A
wire is threaded through the artery" describes the mechanical embolus removal in cerebral
ischemia (MERCI) procedure.
A patient admitted with possible stroke has been aphasic for 3 hours, and his current blood
pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse
, question? a. Keep head of bed elevated at least 30 degrees.
b. Infuse normal saline intravenously at 75 mL/hr.
c. Start a labetalol drip to keep BP less than 140/90 mm Hg.
d. Administer tissue plasminogen activator (tPA) intravenously per protocol. correct answers C
Because elevated BP may be a protective response to maintain cerebral perfusion,
antihypertensive therapy is recommended only if mean arterial pressure (MAP) is greater
than130 mm Hg or systolic pressure is greater than 220 mm Hg. Fluid intake should be 1500
to 2000 mL/day to maintain cerebral blood flow. The head of the bed should be elevated to at
least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be
administered if the patient meets the other criteria for tPA use.
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2
hours previously, and health records show a history of several transient ischemic attacks
(TIAs). The nurse anticipates preparing the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin drip administration.
d. tissue plasminogen activator (tPA) infusion. correct answers D
The patient's history and clinical manifestations suggest an acute ischemic stroke, and a
patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening
with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent
carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is
having an acute ischemic stroke.
A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate
nursing intervention to help the patient communicate is to
a. ask questions that the patient can answer with "yes" or "no."
b. develop a list of words that the patient can read and practice reciting.
c. have the patient practice her facial and tongue exercises with a mirror.
d. prevent embarrassing the patient by answering for her if she does not respond. correct answers
A
Communication will be facilitated and less frustrating to the patient when questions that
require a "yes" or "no" response are used. When the language areas of the brain are injured,
the patient might not be able to read or recite words, which will frustrate the patient without
improving communication. Expressive aphasia is caused by damage to the language areas of
the brain, not by the areas that control the motor aspects of speech. The nurse should allow
time for the patient to respond.
For a patient who had a right hemisphere stroke, the nurse anticipates planning interventions
to manage
a. impaired physical mobility related to right-sided hemiplegia.
b. risk for injury related to denial of deficits and impulsiveness.
c. impaired verbal communication related to speech-language deficits.
d. ineffective coping related to depression and distress about disability. correct answers B
The patient with right-sided brain damage typically denies any deficits and has poor impulse
control, leading to risk for injury when the patient attempts activities such as transferring from
When admitting an acutely confused patient with a head injury, which action should the nurse
take?
a. Ask family members about the patient's health history.
b. Ask leading questions to assist in obtaining health data.
c. Wait until the patient is better oriented to ask questions.
d. Obtain only the physiologic neurologic assessment data. correct answers A
When admitting a patient who is likely to be a poor historian, the nurse should obtain health
history information from others who have knowledge about the patient's health. Waiting until
the patient is oriented or obtaining only physiologic data will result in incomplete assessment
data, which could adversely affect decision making about treatment. Asking leading questions
may result in inaccurate or incomplete information.
Which finding would the nurse expect when assessing the legs of a patient who has a lower
motor neuron lesion?
a. Spasticity c. Impaired sensation
b. Flaccidity d. Hyperactive reflexes correct answers B
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the
neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive
reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor
neuron lesions.
The nurse performing a focused assessment of left posterior temporal lobe functions will
assess the patient for
a. sensation on the left side of the body.
b. reasoning and problem-solving ability.
c. ability to understand written and oral language.
d. voluntary movements on the right side of the body. correct answers C
The posterior temporal lobe integrates the visual and auditory input for language
comprehension. Reasoning and problem solving are functions of the anterior frontal lobe.
Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary
movement on the right side is controlled in the left precentral gyrus.
4. Propranolol (Inderal), a -adrenergic blocker that inhibits sympathetic nervous system
activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse
monitors the patient for
a. dry mouth. c. constipation.
b. bradycardia. d. urinary retention. correct answers B
Inhibition of the fight-or-flight response leads to a decreased heart rate. Dry mouth,
constipation, and urinary retention are associated with peripheral nervous system blockade.
5. To assess the functions of the trigeminal and facial nerves (CNs V and VII), the nurse should
a. check for unilateral eyelid droop.
b. shine a light into the patient's pupil.
c. touch a cotton wisp strand to the cornea.
,d. have the patient read a magazine or book. correct answers C
The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is
tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response
to light and ptosis are used to evaluate function of the oculomotor nerve.
Which action will the nurse include in the plan of care for a patient with impaired functioning
of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?
a. Assist to stand and ambulate. c. Insert an oropharyngeal airway.
b. Withhold oral fluids and food. d. Apply artificial tears every hour. correct answers B
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A
patient with impaired function of these nerves is at risk for aspiration. An oral airway may be
needed when a patient is unconscious and unable to maintain the airway, but it will not
decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. Balance and
coordination are cerebellar functions.
An unconscious male patient has just arrived in the emergency department with a head injury
caused by a motorcycle crash. Which order should the nurse question?
a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c. Send for computed tomography (CT) scan.
d. Perform neurologic checks every 15 minutes. correct answers B
After a head injury, the patient may be experiencing intracranial bleeding and increased
intracranial pressure, and herniation of the brain could result if lumbar puncture is performed.
The other orders are appropriate.
. After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no
residual effects, the nurse anticipates teaching the patient about
a. cerebral aneurysm clipping. c. oral low-dose aspirin therapy.
b. heparin intravenous infusion. d. tissue plasminogen activator (tPA). correct answers C
The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that
inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin
infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms
are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not
for TIA.
A patient is being admitted with a possible stroke. Which information from the assessment
indicates that the nurse should consult with the health care provider before giving the
prescribed aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient reports that symptoms began with a severe headache.
d. The patient has a history of brief episodes of right-sided hemiplegia. correct answers C
A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is
contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack are not
contraindications to aspirin use.
,A patient with a stroke experiences facial drooping on the right side and right-sided arm and
leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to
find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions correct answers D
Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with
comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive
behavior and neglect are more likely with a right-side stroke.
During the change of shift report, a nurse is told that a patient has an occluded left posterior
cerebral artery. The nurse will anticipate that the patient may have
a. dysphasia. c. visual deficits.
b. confusion. d. poor judgment. correct answers C
Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with
middle cerebral artery involvement. Cognitive deficits and changes in judgment are more
typical of anterior cerebral artery occlusion.
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral
atherosclerosis
a. to monitor and record the blood pressure daily.
b. to call the health care provider if stools are tarry.
c. that clopidogrel will dissolve clots in the cerebral arteries.
d. that clopidogrel will reduce cerebral artery plaque formation. correct answers B
Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, so
patients should be advised to notify the health care provider about any signs of bleeding. The
medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy.
Which response by the nurse is accurate?
a. "The obstructing plaque is surgically removed from inside an artery in the neck."
b. "The diseased portion of the artery in the brain is replaced with a synthetic graft."
c. "A wire is threaded through an artery in the leg to the clots in the carotid artery,
and the clots are removed."
d. "A catheter with a deflated balloon is positioned at the narrow area, and the
balloon is inflated to flatten the plaque." correct answers A
In a carotid endarterectomy, the carotid artery is incised, and the plaque is removed. The
response beginning, "The diseased portion of the artery in the brain is replaced" describes an
arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is
positioned at the narrow area" describes an angioplasty. The final response beginning, "A
wire is threaded through the artery" describes the mechanical embolus removal in cerebral
ischemia (MERCI) procedure.
A patient admitted with possible stroke has been aphasic for 3 hours, and his current blood
pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse
, question? a. Keep head of bed elevated at least 30 degrees.
b. Infuse normal saline intravenously at 75 mL/hr.
c. Start a labetalol drip to keep BP less than 140/90 mm Hg.
d. Administer tissue plasminogen activator (tPA) intravenously per protocol. correct answers C
Because elevated BP may be a protective response to maintain cerebral perfusion,
antihypertensive therapy is recommended only if mean arterial pressure (MAP) is greater
than130 mm Hg or systolic pressure is greater than 220 mm Hg. Fluid intake should be 1500
to 2000 mL/day to maintain cerebral blood flow. The head of the bed should be elevated to at
least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be
administered if the patient meets the other criteria for tPA use.
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2
hours previously, and health records show a history of several transient ischemic attacks
(TIAs). The nurse anticipates preparing the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin drip administration.
d. tissue plasminogen activator (tPA) infusion. correct answers D
The patient's history and clinical manifestations suggest an acute ischemic stroke, and a
patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening
with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent
carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is
having an acute ischemic stroke.
A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate
nursing intervention to help the patient communicate is to
a. ask questions that the patient can answer with "yes" or "no."
b. develop a list of words that the patient can read and practice reciting.
c. have the patient practice her facial and tongue exercises with a mirror.
d. prevent embarrassing the patient by answering for her if she does not respond. correct answers
A
Communication will be facilitated and less frustrating to the patient when questions that
require a "yes" or "no" response are used. When the language areas of the brain are injured,
the patient might not be able to read or recite words, which will frustrate the patient without
improving communication. Expressive aphasia is caused by damage to the language areas of
the brain, not by the areas that control the motor aspects of speech. The nurse should allow
time for the patient to respond.
For a patient who had a right hemisphere stroke, the nurse anticipates planning interventions
to manage
a. impaired physical mobility related to right-sided hemiplegia.
b. risk for injury related to denial of deficits and impulsiveness.
c. impaired verbal communication related to speech-language deficits.
d. ineffective coping related to depression and distress about disability. correct answers B
The patient with right-sided brain damage typically denies any deficits and has poor impulse
control, leading to risk for injury when the patient attempts activities such as transferring from
