MDC 4 Exam 1 Review A and B combined
Questions With Correct Answers
1. A client has been in a MVC and presents with signs and symptoms of
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increased intracranial pressure. What is the most significant sign or
| | | | | | | | | |
symptoms in increased ICP? | | |
a. Pupil changes
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b. Ipsilateral paralysis
| |
c. Vomiting
|
d. Decrease in LOC
| | |
D
2. A client has recently suffered a stroke with left-sided weakness. A
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nurse assesses for dysphagia, especially with thin liquids. Which nursing
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intervention is most helpful in assessing this client to swallow safely?
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a. The client should avoid all liquids
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b. Instructing to tuck the chin when swallowing
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c. Give sips of water with each bite
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,d. Turn head to the left
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B
3. A nurse assesses a 27 y.o. female client who presents with muscle
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weakness and decreased muscle coordination over the past few
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months. What nervous system disease is she most likely suffering from?
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a. Systemic lupus erythematous
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b. Multiple sclerosis
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c. Guillain-Barre syndrome
| |
d. Myasthenia gravis
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B
4. During an assessment of a recent seizure client, the nurse interprets
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which finding is congruent with the postictal state?
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a. The clients motor function is returning to baseline
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b. The client states there is a visible aura
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c. The client has brief jerking of the extremities
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d. The client O2 saturation is 80%
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,A
5. The client has a head injury and is presenting with signs and
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symptoms of increased ICP. Which nursing intervention would be helpful
| | | | | | | | |
in reducing this pressure?
| | | |
a. Place the neck in a neutral position to promote venous drainage
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b. Suction hourly to stimulate the cough reflex
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c. Add extra blankets to keep the client warm
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d. Turn the client frequently to prevent skin impairment
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A
6. A client injured in an MVA is being evaluated at the emergency
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department for a possible head injury. Which test should NOT be done if
| | | | | | | | | | | |
there is indication of increased ICP?
| | | | | |
a. CT Scan
| |
b. MRI Scan
| |
c. Lumbar Puncture
| |
d. Electroencephalogram
|
, C
7. The nurse is obtaining a health history for a 45-year-old woman with
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Guillain-Barré syndrome (GBS). Which statement by the client does the
| | | | | | | | | |
nurse correlate with the client's diagnosis?
| | | | |
a. "I have a history of a cardiac dysrhythmia.
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b. "I just got over the flu a couple of weeks ago, and now this."
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c. "My neighbor also has Guillain-Barré syndrome."
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d. "I am an artist and work with oil paints."
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B
8. A client arrives in the emergency department with an ischemic stroke.
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Because the healthcare team is considering administering tissue
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plasminogen activator (t-PA), what should the nurse perform first?
| | | | | | | |
a. Ask what medications the client is taking
| | | | | | |
b. Complete the history and health assessment
| | | | | |
c. Identify the time of onset of the stroke
| | | | | | | |
Determine if the client is scheduled for any surgical procedures
| | | | | | | | |
Questions With Correct Answers
1. A client has been in a MVC and presents with signs and symptoms of
| | | | | | | | | | | | | | |
increased intracranial pressure. What is the most significant sign or
| | | | | | | | | |
symptoms in increased ICP? | | |
a. Pupil changes
| |
b. Ipsilateral paralysis
| |
c. Vomiting
|
d. Decrease in LOC
| | |
D
2. A client has recently suffered a stroke with left-sided weakness. A
| | | | | | | | | | | |
nurse assesses for dysphagia, especially with thin liquids. Which nursing
| | | | | | | | | |
intervention is most helpful in assessing this client to swallow safely?
| | | | | | | | | |
a. The client should avoid all liquids
| | | | | |
b. Instructing to tuck the chin when swallowing
| | | | | | |
c. Give sips of water with each bite
| | | | | | |
,d. Turn head to the left
| | | | |
B
3. A nurse assesses a 27 y.o. female client who presents with muscle
| | | | | | | | | | | | |
weakness and decreased muscle coordination over the past few
| | | | | | | | |
months. What nervous system disease is she most likely suffering from?
| | | | | | | | | |
a. Systemic lupus erythematous
| | |
b. Multiple sclerosis
| |
c. Guillain-Barre syndrome
| |
d. Myasthenia gravis
| |
B
4. During an assessment of a recent seizure client, the nurse interprets
| | | | | | | | | | | |
which finding is congruent with the postictal state?
| | | | | | |
a. The clients motor function is returning to baseline
| | | | | | | |
b. The client states there is a visible aura
| | | | | | | |
c. The client has brief jerking of the extremities
| | | | | | | |
d. The client O2 saturation is 80%
| | | | | |
,A
5. The client has a head injury and is presenting with signs and
| | | | | | | | | | | | |
symptoms of increased ICP. Which nursing intervention would be helpful
| | | | | | | | |
in reducing this pressure?
| | | |
a. Place the neck in a neutral position to promote venous drainage
| | | | | | | | | | |
b. Suction hourly to stimulate the cough reflex
| | | | | | |
c. Add extra blankets to keep the client warm
| | | | | | | |
d. Turn the client frequently to prevent skin impairment
| | | | | | | |
A
6. A client injured in an MVA is being evaluated at the emergency
| | | | | | | | | | | | |
department for a possible head injury. Which test should NOT be done if
| | | | | | | | | | | |
there is indication of increased ICP?
| | | | | |
a. CT Scan
| |
b. MRI Scan
| |
c. Lumbar Puncture
| |
d. Electroencephalogram
|
, C
7. The nurse is obtaining a health history for a 45-year-old woman with
| | | | | | | | | | | | |
Guillain-Barré syndrome (GBS). Which statement by the client does the
| | | | | | | | | |
nurse correlate with the client's diagnosis?
| | | | |
a. "I have a history of a cardiac dysrhythmia.
| | | | | | | |
b. "I just got over the flu a couple of weeks ago, and now this."
| | | | | | | | | | | | | |
c. "My neighbor also has Guillain-Barré syndrome."
| | | | | |
d. "I am an artist and work with oil paints."
| | | | | | | | |
B
8. A client arrives in the emergency department with an ischemic stroke.
| | | | | | | | | | |
Because the healthcare team is considering administering tissue
| | | | | | | | |
plasminogen activator (t-PA), what should the nurse perform first?
| | | | | | | |
a. Ask what medications the client is taking
| | | | | | |
b. Complete the history and health assessment
| | | | | |
c. Identify the time of onset of the stroke
| | | | | | | |
Determine if the client is scheduled for any surgical procedures
| | | | | | | | |
