CCRI Med Surg 1020 Exam 3 Questions With Complete
Solutions
A 50-yr-old man reports recurring headaches. He describes them
as sharp, stabbing, and around his left eye. He says his left eye
seems to swell and get teary when these headaches occur. Based
on this history, you suspect he has
a. cluster headaches.
b. tension headaches.
c. migraine headaches.
d. medication overuse headaches. Correct Answers a. cluster
headaches.
Rationale: Cluster headaches involve repeated headaches that
can occur for weeks to months, followed by periods of
remission. The pain of cluster headache is sharp and stabbing. It
lasts a few minutes to 3 hours. Cluster headaches can occur
every other day and as often as 8 times a day. The clusters occur
with regularity, usually at the same time each day and during the
same seasons of the year. The pain usually is around the eye and
radiates to the temple, forehead, cheek, nose, or gums. Other
manifestations may include swelling around the eye, lacrimation
(tearing), facial flushing or pallor, nasal congestion, and
constriction of the pupil.
A 65-yr-old woman was just diagnosed with Parkinson's disease.
The priority nursing intervention is
a. searching the Internet for educational videos.
,b. helping the caregiver explore respite care options.
c. promoting physical exercise and a well-balanced diet.
d. teaching about the benefits and risks of ablation surgery.
Correct Answers c. promoting physical exercise and a well-
balanced diet.
Rationale: Promoting physical exercise and a well-balanced diet
are major concerns of nursing care for patients newly diagnosed
with Parkinson's disease. Diet is of major concern as
malnutrition and constipation can result from poor nutrition.
Exercise can limit the effects of decreased mobility, such as
muscle atrophy, contractures, and constipation. Helping the
patient and caregiver explore respite care options may be
appropriate later in the course of PD.
A 74-yr-old man who has right-sided extremity paralysis related
to a thrombotic stroke develops constipation. Which action
should the nurse take first?
Assist the patient to the bathroom every 2 hours.
Provide incontinence briefs to wear during the day.
Give a bisacodyl (Dulcolax) rectal suppository every day.
Provide several servings daily of cooked fruits and vegetables.
Correct Answers Correct Answer:
Provide several servings daily of cooked fruits and vegetables.
Rationale:
Patients after a stroke often have constipation. Dietary
management includes the following: fluid intake of 2500 to
3000 mL daily, prune juice (120 mL) or stewed prunes daily,
cooked fruit 3 times daily, cooked vegetables 3 times daily, and
,whole-grain cereal or bread 3 to 5 times daily. Patients with
urinary incontinence should be assisted to the bathroom every 2
hours. Suppositories may be ordered for short-term management
if the patient does not respond to increased fluid and fiber.
Incontinence briefs are indicated as a short-term intervention for
urinary incontinence.
A CT scan of a patient's head reveals a hemorrhagic stroke.
What is the priority nursing intervention in the emergency
department?
Maintaining the patient's airway
Positioning to promote cerebral perfusion
Controlling fluid and electrolyte imbalances
Administering tissue plasminogen activator (tPA) Correct
Answers Correct Answer:
Maintaining the patient's airway
Rationale:
Maintaining a patent airway is the priority in the acute care of a
patient with a hemorrhagic stroke. It supersedes the importance
of fluid and electrolyte imbalance and positioning. tPA is
contraindicated in hemorrhagic stroke.
A female patient presents to the emergency department reporting
the most severe headache of her life. Which type of stroke
should the nurse anticipate?
TIA
Embolic stroke
Thrombotic stroke
, Subarachnoid hemorrhage Correct Answers Correct Answer:
Subarachnoid hemorrhage
Rationale:
Headache is common in a patient who has a subarachnoid
hemorrhage or an intracerebral hemorrhage. A TIA is a transient
loss of neurologic function usually without a headache. A
headache may occur with an ischemic embolic stroke, but severe
neurologic deficits are the initial symptoms. The ischemic
thrombotic stroke manifestations progress in the first 72 hours as
infarction and cerebral edema increase.
A female patient reports a throbbing headache. The nurse learns
the patient has had photophobia and headaches previously.
Which diagnosis should the nurse suspect?
Cluster headache
Migraine headache
Polycythemia vera
Hemorrhagic stroke Correct Answers Correct Answer:
Migraine headache
Rationale:
Although a headache may occur with any of these options, a
migraine headache is the only one that has a throbbing headache
with an aura (the photophobia). Headache from polycythemia
vera is from erythrocytosis. The cluster headache pain is sharp
and stabbing. The headache associated with a hemorrhagic
stroke has a sudden onset and is not recurrent.
Solutions
A 50-yr-old man reports recurring headaches. He describes them
as sharp, stabbing, and around his left eye. He says his left eye
seems to swell and get teary when these headaches occur. Based
on this history, you suspect he has
a. cluster headaches.
b. tension headaches.
c. migraine headaches.
d. medication overuse headaches. Correct Answers a. cluster
headaches.
Rationale: Cluster headaches involve repeated headaches that
can occur for weeks to months, followed by periods of
remission. The pain of cluster headache is sharp and stabbing. It
lasts a few minutes to 3 hours. Cluster headaches can occur
every other day and as often as 8 times a day. The clusters occur
with regularity, usually at the same time each day and during the
same seasons of the year. The pain usually is around the eye and
radiates to the temple, forehead, cheek, nose, or gums. Other
manifestations may include swelling around the eye, lacrimation
(tearing), facial flushing or pallor, nasal congestion, and
constriction of the pupil.
A 65-yr-old woman was just diagnosed with Parkinson's disease.
The priority nursing intervention is
a. searching the Internet for educational videos.
,b. helping the caregiver explore respite care options.
c. promoting physical exercise and a well-balanced diet.
d. teaching about the benefits and risks of ablation surgery.
Correct Answers c. promoting physical exercise and a well-
balanced diet.
Rationale: Promoting physical exercise and a well-balanced diet
are major concerns of nursing care for patients newly diagnosed
with Parkinson's disease. Diet is of major concern as
malnutrition and constipation can result from poor nutrition.
Exercise can limit the effects of decreased mobility, such as
muscle atrophy, contractures, and constipation. Helping the
patient and caregiver explore respite care options may be
appropriate later in the course of PD.
A 74-yr-old man who has right-sided extremity paralysis related
to a thrombotic stroke develops constipation. Which action
should the nurse take first?
Assist the patient to the bathroom every 2 hours.
Provide incontinence briefs to wear during the day.
Give a bisacodyl (Dulcolax) rectal suppository every day.
Provide several servings daily of cooked fruits and vegetables.
Correct Answers Correct Answer:
Provide several servings daily of cooked fruits and vegetables.
Rationale:
Patients after a stroke often have constipation. Dietary
management includes the following: fluid intake of 2500 to
3000 mL daily, prune juice (120 mL) or stewed prunes daily,
cooked fruit 3 times daily, cooked vegetables 3 times daily, and
,whole-grain cereal or bread 3 to 5 times daily. Patients with
urinary incontinence should be assisted to the bathroom every 2
hours. Suppositories may be ordered for short-term management
if the patient does not respond to increased fluid and fiber.
Incontinence briefs are indicated as a short-term intervention for
urinary incontinence.
A CT scan of a patient's head reveals a hemorrhagic stroke.
What is the priority nursing intervention in the emergency
department?
Maintaining the patient's airway
Positioning to promote cerebral perfusion
Controlling fluid and electrolyte imbalances
Administering tissue plasminogen activator (tPA) Correct
Answers Correct Answer:
Maintaining the patient's airway
Rationale:
Maintaining a patent airway is the priority in the acute care of a
patient with a hemorrhagic stroke. It supersedes the importance
of fluid and electrolyte imbalance and positioning. tPA is
contraindicated in hemorrhagic stroke.
A female patient presents to the emergency department reporting
the most severe headache of her life. Which type of stroke
should the nurse anticipate?
TIA
Embolic stroke
Thrombotic stroke
, Subarachnoid hemorrhage Correct Answers Correct Answer:
Subarachnoid hemorrhage
Rationale:
Headache is common in a patient who has a subarachnoid
hemorrhage or an intracerebral hemorrhage. A TIA is a transient
loss of neurologic function usually without a headache. A
headache may occur with an ischemic embolic stroke, but severe
neurologic deficits are the initial symptoms. The ischemic
thrombotic stroke manifestations progress in the first 72 hours as
infarction and cerebral edema increase.
A female patient reports a throbbing headache. The nurse learns
the patient has had photophobia and headaches previously.
Which diagnosis should the nurse suspect?
Cluster headache
Migraine headache
Polycythemia vera
Hemorrhagic stroke Correct Answers Correct Answer:
Migraine headache
Rationale:
Although a headache may occur with any of these options, a
migraine headache is the only one that has a throbbing headache
with an aura (the photophobia). Headache from polycythemia
vera is from erythrocytosis. The cluster headache pain is sharp
and stabbing. The headache associated with a hemorrhagic
stroke has a sudden onset and is not recurrent.
