1538 exam 2 questions and answers
with solutions
kernig's sign - ANSWER a nurse is assessing a client with meningitis. the nurse places the client
in a supine position and flexes the client's leg at the hip and knee. the nurse notes resistance
when straightening the knee and the client reports pain. the nurse should document what
neurologic sign as positive?
a positive kernig's sign - ANSWER is a manifestation of meningeal irritation.
kernig's sign - ANSWER the nurse can elicit this sign by placing the client in a supine position and
flexing the leg at the hip and knee. pain or resistance when the knee is straightened suggests
meningeal irritation.
babinski's reflex - ANSWER dorsiflexion of the great toe with extension fanning of the other toes
is an abnormal reflex elicited by firmly stroking the lateral aspect of the feet with a blunt object.
babinski's reflex - ANSWER is an indicator of corticospinal damage.
brudzinski's sign - ANSWER flexion of the hips and knees in response to positive flexion of the
neck that also signals meningeal irritation.
lichtheim's sign - ANSWER is the inability to speak associated with subcortical aphasia.
the decision is whether you want to honor their wishes concerning organ donation. - ANSWER a
coordinator from an organ procurement agency is leading a meeting with a physician, a nurse,
and the parent of a client with confirmed brain death. the client's driver's license indicates that
they are an organ donor. after the meeting, the client's parent states, i just can't make the
decision to let him die. which response by the nurse is best?
,the client can be pronounced dead - ANSWER because the client meets the criteria for brain
death.
although the required position may not be comfortable, it will make the procedure safer and
easier to perform. - ANSWER a client preparing to undergo a lumbar puncture states they don't
think they will be able to get comfortable with their knees drawn up to the abdomen and the
chin touching their chest. the client asks if they can lie on their left side. which statement is the
best response by the nurse?
the knee-chest position - ANSWER is necessary to make the procedure of lumbar puncture safer
and easier to perform.
conductive hearing loss - ANSWER audiometry confirms a client's chronic progressive hearing
loss. further investigation reveals ankylosis of the stapes in the oval window, a condition that
prevents sound transmission. this type of hearing loss is called....
conductive hearing loss - ANSWER results from interference with the conduction of sound
waves from the tympanic membrane to the inner ear. the stapes must move freely for sound to
be transmitted. bone tissue overgrowth causes the stapes to become fixed or immobile in the
oval window, preventing sound transmission.
functional hearing loss - ANSWER no organic lesion is found
fluctuating hearing loss - ANSWER a form of sensorineural hearing loss that varies over time.
sensorineural hearing loss - ANSWER affects the inner ear and involves the cochlea and 8th
cranial nerve
,absence of reflexes along with flaccid extremities - ANSWER a client with quadriplegia is in
spinal shock. what finding should the nurse expect?
spinal shock occurs - ANSWER during the period immediately following a spinal cord injury
in spinal shock - ANSWER all reflexes are absent and the extremities are flaccid.
jugular vein distention - ANSWER a nurse is assessing a client with syndrome of inappropriate
antidiuretic hormone. which finding requires further action?
JVD - ANSWER signals vascular fluid overload
it is a chronic disease in which there is a disturbance in nerve transmission to the muscle,
resulting in fatigue and muscle weakness. - ANSWER a client with a new diagnosis of myasthenia
gravis asks, what is happening to me? what would be the most appropriate response by the
nurse?
myasthenia gravis - ANSWER a neuromuscular disorder that progresses very rapidly and has
profound fatigue and muscle weakness
MS - ANSWER a debilitating disease involving the myelin sheath
huntington's chorea - ANSWER a chronic disease with a disturbance in nerve transmission
amyotrophic lateral sclerosis - ANSWER a progressive, degenerative disease involving lower
motor neurons
, increased intracranial pressure - ANSWER the nurse is assessing a client with a head injury. on
admission, the pupils were equal; now the right pupil is fully dilated and nonreactive, and the
left pupil is 4 mm and reacts to light. what would this change in neurologic status suggest to the
nurse?
ensure that oxygen is flowing at 5 liters per minute by nasal cannula.
check the client's pulse oximetry reading every 1 hour. - ANSWER a client is stabilized in the
emergency department and moved to the neurologic intensive care unit with a diagnosis of
spinal cord injury at level C4-C5. the nurse is working with an experienced unlicensed assistive
personnel. which items can the nurse delegate to the UAP? select all that apply.
you should review this info with your healthcare provider at every admission. - ANSWER a 35
year old client diagnosed with multiple sclerosis three years ago presents the nurse with an
advance directive refusing intubation, mechanical ventilation, and tube feedings. how should
the nurse respond?
ischemic stroke - ANSWER blood supply is interrupted by thrombus, embolus, or stenosis.
hemorrhagic stroke - ANSWER ruptured blood vessel
stroke - ANSWER 5th leading cause of death in the US
more common in men
highest incidence in over 65 age group
the leading cause of serious long term disability in the US
financial impact can be profound
- CT without contrast because contrast can mask the bleed
ischemic stroke - ANSWER blood flow blocked by blockage or stenosis of a cerebral artery
with solutions
kernig's sign - ANSWER a nurse is assessing a client with meningitis. the nurse places the client
in a supine position and flexes the client's leg at the hip and knee. the nurse notes resistance
when straightening the knee and the client reports pain. the nurse should document what
neurologic sign as positive?
a positive kernig's sign - ANSWER is a manifestation of meningeal irritation.
kernig's sign - ANSWER the nurse can elicit this sign by placing the client in a supine position and
flexing the leg at the hip and knee. pain or resistance when the knee is straightened suggests
meningeal irritation.
babinski's reflex - ANSWER dorsiflexion of the great toe with extension fanning of the other toes
is an abnormal reflex elicited by firmly stroking the lateral aspect of the feet with a blunt object.
babinski's reflex - ANSWER is an indicator of corticospinal damage.
brudzinski's sign - ANSWER flexion of the hips and knees in response to positive flexion of the
neck that also signals meningeal irritation.
lichtheim's sign - ANSWER is the inability to speak associated with subcortical aphasia.
the decision is whether you want to honor their wishes concerning organ donation. - ANSWER a
coordinator from an organ procurement agency is leading a meeting with a physician, a nurse,
and the parent of a client with confirmed brain death. the client's driver's license indicates that
they are an organ donor. after the meeting, the client's parent states, i just can't make the
decision to let him die. which response by the nurse is best?
,the client can be pronounced dead - ANSWER because the client meets the criteria for brain
death.
although the required position may not be comfortable, it will make the procedure safer and
easier to perform. - ANSWER a client preparing to undergo a lumbar puncture states they don't
think they will be able to get comfortable with their knees drawn up to the abdomen and the
chin touching their chest. the client asks if they can lie on their left side. which statement is the
best response by the nurse?
the knee-chest position - ANSWER is necessary to make the procedure of lumbar puncture safer
and easier to perform.
conductive hearing loss - ANSWER audiometry confirms a client's chronic progressive hearing
loss. further investigation reveals ankylosis of the stapes in the oval window, a condition that
prevents sound transmission. this type of hearing loss is called....
conductive hearing loss - ANSWER results from interference with the conduction of sound
waves from the tympanic membrane to the inner ear. the stapes must move freely for sound to
be transmitted. bone tissue overgrowth causes the stapes to become fixed or immobile in the
oval window, preventing sound transmission.
functional hearing loss - ANSWER no organic lesion is found
fluctuating hearing loss - ANSWER a form of sensorineural hearing loss that varies over time.
sensorineural hearing loss - ANSWER affects the inner ear and involves the cochlea and 8th
cranial nerve
,absence of reflexes along with flaccid extremities - ANSWER a client with quadriplegia is in
spinal shock. what finding should the nurse expect?
spinal shock occurs - ANSWER during the period immediately following a spinal cord injury
in spinal shock - ANSWER all reflexes are absent and the extremities are flaccid.
jugular vein distention - ANSWER a nurse is assessing a client with syndrome of inappropriate
antidiuretic hormone. which finding requires further action?
JVD - ANSWER signals vascular fluid overload
it is a chronic disease in which there is a disturbance in nerve transmission to the muscle,
resulting in fatigue and muscle weakness. - ANSWER a client with a new diagnosis of myasthenia
gravis asks, what is happening to me? what would be the most appropriate response by the
nurse?
myasthenia gravis - ANSWER a neuromuscular disorder that progresses very rapidly and has
profound fatigue and muscle weakness
MS - ANSWER a debilitating disease involving the myelin sheath
huntington's chorea - ANSWER a chronic disease with a disturbance in nerve transmission
amyotrophic lateral sclerosis - ANSWER a progressive, degenerative disease involving lower
motor neurons
, increased intracranial pressure - ANSWER the nurse is assessing a client with a head injury. on
admission, the pupils were equal; now the right pupil is fully dilated and nonreactive, and the
left pupil is 4 mm and reacts to light. what would this change in neurologic status suggest to the
nurse?
ensure that oxygen is flowing at 5 liters per minute by nasal cannula.
check the client's pulse oximetry reading every 1 hour. - ANSWER a client is stabilized in the
emergency department and moved to the neurologic intensive care unit with a diagnosis of
spinal cord injury at level C4-C5. the nurse is working with an experienced unlicensed assistive
personnel. which items can the nurse delegate to the UAP? select all that apply.
you should review this info with your healthcare provider at every admission. - ANSWER a 35
year old client diagnosed with multiple sclerosis three years ago presents the nurse with an
advance directive refusing intubation, mechanical ventilation, and tube feedings. how should
the nurse respond?
ischemic stroke - ANSWER blood supply is interrupted by thrombus, embolus, or stenosis.
hemorrhagic stroke - ANSWER ruptured blood vessel
stroke - ANSWER 5th leading cause of death in the US
more common in men
highest incidence in over 65 age group
the leading cause of serious long term disability in the US
financial impact can be profound
- CT without contrast because contrast can mask the bleed
ischemic stroke - ANSWER blood flow blocked by blockage or stenosis of a cerebral artery
