Exam (elaborations) NURS 1102 PASSPOINT NEURO

NURS 1102 PASSPOINT NEURO Question 1 See full question A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate? You Selected:  Increased intracranial pressure (ICP) Correct response:  Meningeal irritation Explanation: Remediation: Question 2 See full question What should a nurse do when administering pilocarpine? You Selected:  Apply pressure on the outer canthus to prevent adverse reactions. Correct response:  Apply pressure on the inner canthus to prevent systemic absorption. Explanation: Remediation: Question 3 See full question A registered nurse (RN) and licensed practical nurse (LPN) are administering medications on the neurologic floor. The LPN prepares to administer phenytoin to a client with a history of seizures. As the LPN walks into the room, she hands the medication to a nursing assistant. The LPN asks the nursing assistant to give the client the medication after completing the client's morning care. What should the registered nurse do? You Selected:  Take the medication from the nursing assistant and administer it. Correct response:  Remind the LPN that she must administer the medications herself. Explanation: Remediation: NURS 1102 PASSPOINT NEURO Question 4 See full question A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction? You Selected:  "I know that I'll eventually be unable to make decisions. Signing an advance directive now will save my family grief." Correct response:  "I don't really need to sign anything. I'm depending on my physician to tell my family what to do if something bad happens." Explanation: Remediation: Question 5 See full question A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when she: You Selected:  documents medications before administration. Correct response:  documents medications after administration. Explanation: Remediation: Question 6 See full question A 70-year-old, previously well client asks the nurse, "I notice I have tremors. Is this just normal for my age?" What should the nurse tell the client? You Selected:  "You should have your blood pressure checked when this occurs." Correct response:  “You should report this to the health care provider because it may indicate a problem.” Explanation: Remediation: Question 7 See full question Following an infection, the client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for: (Select all that apply.) You Selected:  tinnitus  vertigo  ataxia Correct response:  vertigo  nausea  ataxia Explanation: Question 8 See full question A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage? You Selected:  lying flat without a pillow with the client's head turned to the right Correct response:  head of the bed elevated to 30 degrees with the client's head in a neutral position Explanation: Question 9 See full question The nurse is caring for a client with an injury to the thalamus. The nurse should plan to: You Selected:  monitor the temperature of the bathwater. Correct response:  monitor the temperature of the bathwater. Explanation: Question 10 See full question Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment? You Selected:  Activity level can return to normal; clients can resume regular aerobic exercises. Correct response:  Activity is resumed gradually; the client can resume usual activities in 5 to 6 weeks. Explanation: Remediation: Question 11 See full question A client with glaucoma is to receive 3 gtt of acetazolamide in the left eye. What should the nurse do? You Selected:  Ask the client to close his right eye while administering the drug in the left eye. Correct response:  Have the client look up while the nurse administers the eyedrops. Explanation: Remediation: Question 12 See full question As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability? You Selected:  "I cannot have sexual intercourse because it causes hypertension, but other sexual activity is okay." Correct response:  "I can participate in sexual activity but might not experience orgasm." Explanation: Remediation: Question 13 See full question A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, “Why am I unable to stop talking about these things? I know those days are gone forever.” Which response by the nurse conveys the best understanding of the client’s behavior? You Selected:  "It is a simple escape mechanism to go back and live again in happier times." Correct response:  "Reviewing your losses is a way to help you work through your grief and loss." Explanation: Remediation: Question 14 See full question A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? You Selected:  decreasing systolic blood pressure Correct response:  unequal pupil size Explanation: Question 15 See full question The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client: You Selected:  "Keep active, use stress reduction strategies, and avoid fatigue." Correct response:  "Keep active, use stress reduction strategies, and avoid fatigue." Explanation: Remediation: Question 16 See full question An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction? You Selected:  elevating the foot of the bed to reduce edema Correct response:  pulling up the client under the left shoulder when getting the client out of bed to a chair Explanation: Question 17 See full question After 5 days of hospitalization, a client who is receiving morphine sulfate for pain control asks for pain medication with increasing frequency and exhibits increased anxiety and restlessness. The vital signs are within normal ranges. What is a possible cause of this behavior? You Selected:  The client has developed tolerance to the dose of morphine. Correct response:  The client has developed tolerance to the dose of morphine. Explanation: Remediation: Question 18 See full question When determining how to administer analgesics to a client who has been receiving opiates for pain relief administered by injection, the nurse should consider using patient-controlled analgesia since it is more effective because: You Selected:  two opioids can be administered simultaneously. Correct response:  the client will control the amount of pain medication administered. Explanation: Remediation: Question 19 See full question A client is receiving cyclobenzaprine for management of a herniated lumbar disk. Which finding indicates the drug is providing the intended relief? You Selected:  The client is sedated. Correct response:  The client’s muscles are not in spasm. Explanation: Remediation: Question 20 See full question A client with a lumbar laminectomy ambulates for the first time after surgery and begins to feel faint. Which nursing action would be best until help arrives? You Selected:  Have the client close the eyes for a few minutes. Correct response:  Separate the feet to form a wide base of support and have the client rest against the nurse’s hip. Explanation: Question 21 See full question After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which activity would be contraindicated? You Selected:  performing isometric exercises Correct response:  bending over the sink to wash the face Explanation: Remediation: Question 22 See full question A client returns from surgery after a submucosal resection with nasal packing in place. The nurse should first: You Selected:  determine the degree of pain the client is experiencing. Correct response:  assess the degree of airway obstruction. Explanation: Question 23 See full question The client reports that the nasal packing is uncomfortable and asks when it will be removed. The nurse should tell the client the nasal packing is usually removed: You Selected:  after pain has diminished. Correct response:  24 to 48 hours after surgery. Explanation: Remediation: Question 24 See full question The nurse is instructing a client with Ménière’s disease how to recognize vertigo. The nurse should tell the client to notice: You Selected:  a feeling that the environment is in motion. Correct response:  a feeling that the environment is in motion. Explanation: Remediation: Question 25 See full question After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an: You Selected:  examination of the fundus of the eye. Correct response:  evaluation of the corneal reflex response. Explanation: Remediation: Question 26 See full question A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: You Selected:  touching the cornea with a wisp of cotton. Correct response:  turning the client's head suddenly while holding the eyelids open. Explanation: Remediation: Question 27 See full question When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? You Selected:  Shock Correct response:  Increased intracranial pressure (ICP) Explanation: Question 28 See full question A nurse is giving discharge teaching to a client with an eye injury. Which statement about preventing eye injuries should the nurse include? You Selected:  "Direct all spray nozzles away from your face before spraying." Correct response:  "Direct all spray nozzles away from your face before spraying." Explanation: Question 29 See full question Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease? You Selected:  Risk for injury related to vertigo Correct response:  Risk for injury related to vertigo Explanation: Remediation: Question 30 See full question A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order: You Selected:  Doppler scanning. Correct response:  electromyography (EMG). Explanation: Remediation: Question 31 See full question A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: You Selected:  raccoon's eyes and Battle's sign. Correct response:  raccoon's eyes and Battle's sign. Explanation: Remediation: Question 32 See full question When communicating with a client who has sensory (receptive) aphasia, the nurse should: You Selected:  speak loudly and articulate clearly. Correct response:  use short, simple sentences. Explanation: Remediation: Question 33 See full question A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? You Selected:  Risk for injury related to neurologic deficit Correct response:  Risk for injury related to neurologic deficit Explanation: Remediation: Question 34 See full question A client is receiving an I.V. infusion of mannitol after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? You Selected:  Decreased level of consciousness (LOC) Correct response:  Increased urine output Explanation: Remediation: Question 35 See full question A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? You Selected:  "The most common cause of dementia in the elderly is Alzheimer's disease." Correct response:  "The most common cause of dementia in the elderly is Alzheimer's disease." Explanation: Remediation: Question 36 See full question A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? You Selected:  Position the client with the head turned toward the side of the brain tumor. Correct response:  Administer stool softeners. Explanation: Question 37 See full question A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? You Selected:  Lateral recumbent, with chin resting on flexed knees Correct response:  Lateral recumbent, with chin resting on flexed knees Explanation: Remediation: Question 38 See full question A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention? You Selected:  Paresthesia in the dermatomes near the wounds Correct response:  Urine retention or incontinence Explanation: Remediation: Question 39 See full question A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests? You Selected:  X-ray of the brain, bone marrow aspiration, and EEG Correct response:  EEG, blood cultures, and neuroimaging studies Explanation: Remediation: Question 40 See full question For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? You Selected:  speaking loudly Correct response:  using a "picture board" for the client to point to pictures Explanation: Remediation: Question 41 See full question When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? You Selected:  asking the client to speak louder when tired Correct response:  asking the client to speak louder when tired Explanation: Remediation: Question 42 See full question The client with a lumbar laminectomy asks to be turned onto the side. The nurse should: You Selected:  inform the client that because of the laminectomy, it is possible to only lie supine. Correct response:  get another nurse to help logroll the client into position. Explanation: Remediation: Question 43 See full question A client with Parkinson's disease needs a long time to complete morning care, but becomes annoyed when the nurse offers assistance and refuses all help. Which action