NMNC 4410 – Evidence-Based Practice | University of New Mexico | Exam 2:
Quiz Questions with Answers
A 71-year-old man arrives at the emergency department after his friend found him unconscious
in his apartment. You begin by evaluating his conscious state using the Glasgow Coma Scale
(GCS). You call the patient by his name and get no response. After rubbing your knuckles
against his chest, he opens his eyes and closes them. You then ask him a question, the patient
doesn't utter a word or sound. Finally, you place pressure over the patient's left index fingernail
bed. He moves his hands away due to the stimulus. What's this patient's Glasgow Coma Scale
(GCS) score?
A. GCS 7
B. GCS 8
C. GCS 5
D. GCS 10 A. GCS 7
The nurse in the neurological unit is monitoring a client with a head injury for signs of increased
intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes
documentation of the presence of Cushing's reflex. The nurse determines that the presence of
this reflex is obtained by assessing which item?
A. Motor response
B. Blood pressure
C. Pupillary response
D. Level of consciousness B. Blood
The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a
hemorrhagic stroke. The nurse should place the client in which position?
A. Semi-Fowler's with the hip and the neck flexed
B. Supine and Stoke Appropriate
C. Head of the bed elevated 30 degrees with the head in midline position
D. Prone C. Head of the bed elevated 30 degrees with the head in midline position
, The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a
right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the
appropriate nursing intervention?
A. Provide a pureed diet that is easy for the client to swallow.
B. Inform the client that a feeding tube will be placed if progress is not made.
C. Provide a variety of foods on the meal tray to stimulate the client's appetite.
D. Assist the client to eat with the left hand to build strength. D. Assist the client to eat with
the left hand to build strenght.
The home care nurse is visiting a male client who is recovering at home after suffering a brain
attack (stroke) 2 weeks ago. The client's wife states that the client has difficulty feeding himself
and difficulty swallowing food and fluids. Which would be the initial nursing action?
A. Observe the client feeding himself.
B. Observe the wife feeding the client.
C. Arrange for a home health aide to assist at mealtimes.
D. Instruct the wife in the use of a feeding syringe to feed the client. A. Observe the client
feeding himself.
The nurse has instructed the family of a client with stroke (brain attack) who has hemianopsia
about measures to help the client overcome the deficit. Which statement suggests that the
family understands the measures to use when caring for the client?
A. "We need to remind him to turn his head to scan the lost visual field."
B. "We need to approach him from the impaired field of vision."
C. "We need to place objects in his impaired field of vision."
D. "We need to discourage him from wearing eyeglasses." A. "We need to remind him to
turn his head to scan the lost visual field."
Quiz Questions with Answers
A 71-year-old man arrives at the emergency department after his friend found him unconscious
in his apartment. You begin by evaluating his conscious state using the Glasgow Coma Scale
(GCS). You call the patient by his name and get no response. After rubbing your knuckles
against his chest, he opens his eyes and closes them. You then ask him a question, the patient
doesn't utter a word or sound. Finally, you place pressure over the patient's left index fingernail
bed. He moves his hands away due to the stimulus. What's this patient's Glasgow Coma Scale
(GCS) score?
A. GCS 7
B. GCS 8
C. GCS 5
D. GCS 10 A. GCS 7
The nurse in the neurological unit is monitoring a client with a head injury for signs of increased
intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes
documentation of the presence of Cushing's reflex. The nurse determines that the presence of
this reflex is obtained by assessing which item?
A. Motor response
B. Blood pressure
C. Pupillary response
D. Level of consciousness B. Blood
The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a
hemorrhagic stroke. The nurse should place the client in which position?
A. Semi-Fowler's with the hip and the neck flexed
B. Supine and Stoke Appropriate
C. Head of the bed elevated 30 degrees with the head in midline position
D. Prone C. Head of the bed elevated 30 degrees with the head in midline position
, The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a
right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the
appropriate nursing intervention?
A. Provide a pureed diet that is easy for the client to swallow.
B. Inform the client that a feeding tube will be placed if progress is not made.
C. Provide a variety of foods on the meal tray to stimulate the client's appetite.
D. Assist the client to eat with the left hand to build strength. D. Assist the client to eat with
the left hand to build strenght.
The home care nurse is visiting a male client who is recovering at home after suffering a brain
attack (stroke) 2 weeks ago. The client's wife states that the client has difficulty feeding himself
and difficulty swallowing food and fluids. Which would be the initial nursing action?
A. Observe the client feeding himself.
B. Observe the wife feeding the client.
C. Arrange for a home health aide to assist at mealtimes.
D. Instruct the wife in the use of a feeding syringe to feed the client. A. Observe the client
feeding himself.
The nurse has instructed the family of a client with stroke (brain attack) who has hemianopsia
about measures to help the client overcome the deficit. Which statement suggests that the
family understands the measures to use when caring for the client?
A. "We need to remind him to turn his head to scan the lost visual field."
B. "We need to approach him from the impaired field of vision."
C. "We need to place objects in his impaired field of vision."
D. "We need to discourage him from wearing eyeglasses." A. "We need to remind him to
turn his head to scan the lost visual field."
