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NURS 321 Final Exam – Questions With Fully Explained Solutions

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NURS 321 Final Exam – Questions With Fully Explained Solutions

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Terms in this set (133)



Which of the following would be b, c, and d
appropriate to utilize in diagnosing
increased ICP? Select all that apply.


a. Cranial X-ray
b. CT Scan of the brain
c. Neurological Assessment
d. Ventriculostomy


In assessing the patient with scleroderma for A, B, and C
pending renal crisis, which findings require
an intervention by the nurse? (Select all that
apply.)


A. Significant weight gain
B. Blood pressure 174/100 mm Hg
C. Creatinine 1.9 mg/dL
D. Clear urine output
E. BUN 15 mg/dL


Which is true regarding the d. Sensitivity to normal amounts of acetylcholine is diminished.
pathophysiology of myasthenia gravis
(MG)?


a. An inadequate amount of acetylcholine
(Ach) is released.
b. Acetylcholine (Ach) crosses the synaptic
clefts and attaches to Ach receptors (AchR).
c. T cells or T lymphocytes are produced by
the thymus gland.
d. Sensitivity to normal amounts of
acetylcholine is diminished.


Which type of surgery is usually performed b. Thymectomy
for a patient with myasthenia gravis (MG)?


a. Microvascular decompression
b. Thymectomy
c. Percutaneous rhizotomy
d. Sterotactic radiosurgery

,Which nursing intervention is essential while c. Offering soft foods and thickened liquids per the order of
caring for a patient with myasthenia gravis the speech therapist
(MG)?


a. Keeping the head of the bed in a lowered
position
b. Providing meals when medications are at
trough levels
c. Offering soft foods and thickened liquids
per the order of the speech therapist
d. Encouraging the patient to refrain from
taking breaks by keeping him or her
involved in activities of daily living (ADLs)


A nurse is teaching about nursing actions for b. "Do not offer any kind of diversions to the patient."
caring for patients with Guillain-Barré
syndrome (GBS). Which statement indicates
a need for further teaching?


a. "Do not keep the patient in a single
position."
b. "Do not offer any kind of diversions to the
patient."
c. "Establish methods of communication, and
provide a method to call the nurse."
d. "Discuss the use of analgesics or
nonopioids with the healthcare provider."


Which feature of a cholinergic crisis may a c. Excessive secretions
patient encounter if he or she has
myasthenia gravis (MG)?


a. Pale and cool skin
b. Tachycardia
c. Excessive secretions
d. Flaccid muscles


Which is true regarding a cholinergic crisis? d. It is caused by an excessive intake of anticholinesterase
medication.
a. It is caused by lack of anticholinesterase
medication.
b. It is an exacerbation of myasthenic gravis
weakness that provokes an acute episode of
respiratory failure.
c. It is characterized by a clinical feature
such as tachycardia.
d. It is caused by an excessive intake of
anticholinesterase medication.


Which is a clinical feature of a myasthenic a, c, and e
crisis? Select all that apply.
Rationale: Sweating, excessive secretions, & bradycardia are
a. Tachycardia symptoms of cholinergic crisis
b. Sweating and excessive secretions
c. Pale, cool skin
d. Bradycardia
e. Flaccid muscles

, Which diagnostic test is useful in b. Tensilon test
distinguishing a myasthenic crisis from a
cholinergic crisis?


a. Repetitive nerve stimulation (RNS)
b. Tensilon test
c. Chest computed tomography (CT) scan
d. Serological test


The nurse is caring for a patient with c. Pneumonia
amyotrophic lateral sclerosis (ALS). What
risks require additional actions by the nurse?


a. Seizures
b. Paralysis
c. Pneumonia
d. Muscle spasm


Which are clinical manifestations of b and c
amyotrophic lateral sclerosis (ALS)? Select
all that apply.


a. Double or blurred vision
b. Difficulty swallowing
c. Fasciculation
d. Tremor
e. Memory loss


After assessing a patient with amyotrophic a. Dysarthria
lateral sclerosis, the nurse finds that the oral
communication of the patient is impaired.
Which should the nurse document in the
patient's medical record?


a. Dysarthria
b. Motor neuron death
c. Muscle weakness
d. Respiratory muscle weakness


The nurse is assessing a patient who reports a. Cluster headaches
severe, unrelenting pain in and around the
eye. The pain occurs around the same time
for several weeks, more often at night.
Which kind of headache is the patient most
likely experiencing?


a. Cluster headaches
b. Migraine headaches
c. Episodic tension headaches
d. Chronic tension headaches


Which assessment should the nurse be most b. Vomiting
concerned about for the patient with
increased intracranial pressure (ICP)
following a brain tumor resection?


a. Quarter-sized dried blood on skull
dressing
b. Vomiting
c. Low grade temperature
d. Decreased urine output

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