Matching questions
1-59 of 59
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Which finding would the nurse expect when assessing the legs of a patient who has a
lower motor neuron lesion?
a. Spasticity
b. Flaccidity
c. Impaired sensation
d. Hyperactive reflexes
Give this one a try later!
, b. Flaccidity
Lower motor neuron lesions generally cause weakness or paralysis,
denervation atrophy, hyporeflexia or areflexia, and decreased muscle tone
(flaccidity). Spasticity and hyperactive reflexes are caused by upper motor
neuron damage. Sensation is not impacted by motor neuron lesions.
Which patient problem would the nurse identify as of highest priority for a patient
who has Parkinson‘s disease and is unable to move the facial muscles?
a. Activity intolerance
b. Negative self-image
c. Musculoskeletal problem
d. Nutritionally compromised
Give this one a try later!
d. Nutritionally compromised
The data about the patient indicate that poor nutrition will be a concern
because of decreased swallowing. The other diagnoses may also be
appropriate for a patient with Parkinson's disease, but the data do not
indicate that they are current problems for this patient.
A female patient who had a stroke 24 hours ago has expressive aphasia. Which
intervention would the nurse use to help the patient communicate?
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.
Give this one a try later!
, a. Ask questions that the patient can answer with "yes" or "no."
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.
Which information about a patient who has a new prescription for phenytoin (Dilantin)
indicates that the nurse should consult with the health care provider before
administering the medication?
a. Patient has tonic-clonic seizures.
b. Patient experiences an aura before seizures.
c. Patient's most recent blood pressure is 156/92 mm Hg.
d. Patient has slight elevations in liver function test results.
Give this one a try later!
d. Patient has slight elevations in liver function test results.
Patients with compromised liver function may not be able to metabolize
phenytoin. The health care provider may need to choose another
antiseizure medication. Phenytoin is an appropriate medication for patients
with tonic-clonic seizures, with or without an aura. Hypertension is not a
contraindication for phenytoin therapy.
A patient is being admitted with a possible stroke. Which information from the nursing
assessment indicates that the patient is more likely to be having a hemorrhagic stroke
than a thromboembolic stroke?
a. The patient has intermittent bouts of atrial fibrillation.
b. The patient has had brief episodes of right-sided hemiplegia.
, c. The patient has a history of treatment for infective endocarditis.
d. The patient reports that the symptoms began with a severe headache.
Give this one a try later!
d. The patient reports that the symptoms began with a severe headache.
A sudden onset headache is typical of a subarachnoid hemorrhage. Atrial
fibrillation and infective endocarditis are a risk factors for thrombotic or
embolic stroke. Brief episodes of right-sided hemiplegia are consistent with
transient ischemic attack and risk for embolic stroke.
Which nursing assessment would the nurse consider the priority for a patient being
admitted with a brainstem infarction?
a. Pupil reaction
b. Respiratory rate
c. Reflex reaction time
d. Level of consciousness
Give this one a try later!
b. Respiratory rate
Vital centers that control respiration are located in the medulla and part of
the brainstem. They require priority assessments because changes in
respiratory function may be life threatening. The other information will also
be obtained by the nurse but is not as urgent.
Which action would the nurse include in the plan of care for a patient with impaired
function of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?
a. Assist to stand and ambulate.
b. Withhold oral fluids and food.
c. Insert an oropharyngeal airway.
d. Apply artificial tears every hour.
1-59 of 59
Click a definition to match it with a term
Which finding would the nurse expect when assessing the legs of a patient who has a
lower motor neuron lesion?
a. Spasticity
b. Flaccidity
c. Impaired sensation
d. Hyperactive reflexes
Give this one a try later!
, b. Flaccidity
Lower motor neuron lesions generally cause weakness or paralysis,
denervation atrophy, hyporeflexia or areflexia, and decreased muscle tone
(flaccidity). Spasticity and hyperactive reflexes are caused by upper motor
neuron damage. Sensation is not impacted by motor neuron lesions.
Which patient problem would the nurse identify as of highest priority for a patient
who has Parkinson‘s disease and is unable to move the facial muscles?
a. Activity intolerance
b. Negative self-image
c. Musculoskeletal problem
d. Nutritionally compromised
Give this one a try later!
d. Nutritionally compromised
The data about the patient indicate that poor nutrition will be a concern
because of decreased swallowing. The other diagnoses may also be
appropriate for a patient with Parkinson's disease, but the data do not
indicate that they are current problems for this patient.
A female patient who had a stroke 24 hours ago has expressive aphasia. Which
intervention would the nurse use to help the patient communicate?
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.
Give this one a try later!
, a. Ask questions that the patient can answer with "yes" or "no."
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.
Which information about a patient who has a new prescription for phenytoin (Dilantin)
indicates that the nurse should consult with the health care provider before
administering the medication?
a. Patient has tonic-clonic seizures.
b. Patient experiences an aura before seizures.
c. Patient's most recent blood pressure is 156/92 mm Hg.
d. Patient has slight elevations in liver function test results.
Give this one a try later!
d. Patient has slight elevations in liver function test results.
Patients with compromised liver function may not be able to metabolize
phenytoin. The health care provider may need to choose another
antiseizure medication. Phenytoin is an appropriate medication for patients
with tonic-clonic seizures, with or without an aura. Hypertension is not a
contraindication for phenytoin therapy.
A patient is being admitted with a possible stroke. Which information from the nursing
assessment indicates that the patient is more likely to be having a hemorrhagic stroke
than a thromboembolic stroke?
a. The patient has intermittent bouts of atrial fibrillation.
b. The patient has had brief episodes of right-sided hemiplegia.
, c. The patient has a history of treatment for infective endocarditis.
d. The patient reports that the symptoms began with a severe headache.
Give this one a try later!
d. The patient reports that the symptoms began with a severe headache.
A sudden onset headache is typical of a subarachnoid hemorrhage. Atrial
fibrillation and infective endocarditis are a risk factors for thrombotic or
embolic stroke. Brief episodes of right-sided hemiplegia are consistent with
transient ischemic attack and risk for embolic stroke.
Which nursing assessment would the nurse consider the priority for a patient being
admitted with a brainstem infarction?
a. Pupil reaction
b. Respiratory rate
c. Reflex reaction time
d. Level of consciousness
Give this one a try later!
b. Respiratory rate
Vital centers that control respiration are located in the medulla and part of
the brainstem. They require priority assessments because changes in
respiratory function may be life threatening. The other information will also
be obtained by the nurse but is not as urgent.
Which action would the nurse include in the plan of care for a patient with impaired
function of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?
a. Assist to stand and ambulate.
b. Withhold oral fluids and food.
c. Insert an oropharyngeal airway.
d. Apply artificial tears every hour.
