1.
In teaching the family care of the Alzheimer's patient, the nurse emphasizes which of the following behaviors as a serious threat to safety:
Correct Answer
D. Wandering around
Explanation
The Alzheimer's patient tends to wander around and, unable to focus on cognitive problem solving abilities, usually get lost.
2.
The nurse prepares to administer a mild sedative to the restless Alzheimers's patient. Which of the following is most likely to be prescribed?
Correct Answer
A. Benadryl
Explanation
Barbiturates should be avoided because they depresses the CNS function and can cause confusion, especially in the patient with dementia.
3.
A patient has been recently diagnosed with Alzheimer's disease. When teaching the family about the prognosis, the nurse must explain that:
Correct Answer
A. It progresses gradually with deterioration of functions
Explanation
AD is degenerative and is not curable. A progressive loss of neurologic functioning is the major clinical manifestation of this disease, and therefore, is the priority clinical factor.
4.
When the elderly Alzheimer's client becomes agitated and disoriented, which medication is most likely to be prescribed?
Correct Answer
B. Haldol
Explanation
This antipsychotic medication has proven to be the most effective in decreasing the restlessness and agitation of AD patients.
5.
The nurse assesses a patient experiencing global aphasia. She realizes that this patient:
Correct Answer
D. Cannot talk
Explanation
Global aphasia is injury to the brain centers that results in the disturbance of both verbal and perceptive language functioning.
6.
When increasing intracranial pressure is suspected, the nurse should be alert for what other signs and symptoms?
Correct Answer
D. Projectile vomiting and headache
Explanation
As IICP increases, swelling tissues exert pressure on cerebral blood vessels, the dura mater and other structures in the brain and back of the eye.
7.
The physician restricts IV fluids and orders diuretics for a neurologic client. The rationale for this is:
Correct Answer
C. To reduce cerebral edema
Explanation
The physician is attempting to decrease circulating volume and thereby decreases cerebral edema.
8.
The finding of unequal pupillary response in an unconscious person should alert the nurse to:
Correct Answer
C. Head Injury
Explanation
Unequal pupils in this patient may indicate that the oculomotor nerve is being compressed by IICP.
9.
A young man is in the emergency room with a closed head injury following a car accident. Baseline VS are BP 120/80, P 78, R 20. Which nursing assessment data would indicate a deterioration in his condition?
Correct Answer
D. VS of 160/90, 64, 12.
Explanation
Signs of IICP is hyper-brady-brady, and widened pulse pressure.
10.
A 28-year-old woman complains of extreme muscle weakness and states, "I have to rest even after talking for a little while." The nurse assesses her for other symptoms of:
Correct Answer
B. Myasthenia gravis
Explanation
MG, a disease that causes weakness in voluntary muscles, is most common in women, age 20-30.
11.
Other early symptoms of myasthenia gravis that the nurse assesses are:
Correct Answer
C. Diplopia and ptosis
Explanation
Because of the involvement of the ocular muscles this patient often exhibits a "mask" or sleepy expression.
12.
The nurse is aware that the ultimate danger in this disease is progressive weakness and, eventually, the onset of myasthenic crisis. The complication is:
Correct Answer
D. Respiratory emergency
Explanation
Once the diaphragm and intercostal muscles are affected by the progressive weakness of this disease, a respiratory emergency will ensue.
13.
The medication prescribed for Parkinson's disease acts as a precursor to restore dopamine deficiency. What medication should the nurse give?
Correct Answer
D. Levodopa
Explanation
Levodopa is a synthetic precursor of dopamine and replaces the dopamine deficiency in Parkinson's. Dopamine cannot be given because it does not cross the blood-brain barrier.
14.
The nurse assessesa normal reflex when testing the plantar, or Babinski's in adult. what does she see?
Correct Answer
C. Toes bending downward
Explanation
If the toes flare, and foot turns upward, then the sign is positive and considered an abnormal finding in an adult.
15.
During a neurological assessment, the nurse asks the patient to repeat a series of numbers. she is assessing:
Correct Answer
B. Memory
Explanation
Short-term memory can be easily assessed by asking the patient to repeat numbers or words.
16.
The nurse asks a patient the time, his name, and date. She is assessing:
Correct Answer
A. Level of consciousness
Explanation
the nurse is assessing orientation, a key component of the LOC assessment. If the patient responds positively to all three, then the nurse documents, oriented x 3.
17.
A score of five on the Glasgow Coma Scale is assessed. This assesment indicates that the patient is:
Correct Answer
D. Not responsive
Explanation
When assessing a patient according to GCS, 15 is the highest score in which the patient is still alert and oriented. the lower the score, the less responsive the patient.
18.
Decorticate posturing is the result of:
Correct Answer
B. Injury to the brain stem
Explanation
decorticate posturing is the abnormal manifestation of impingement on the motor pathways of the brainstem.
19.
The patient with tic douloureaux should be carefully assessed for undernourishment and dehydration because:
Correct Answer
A. Chewing is exceedingly painful
Explanation
Trigeminal neuralgia, a painful condition of cranial nerve V causes dysfunction in chewing.
20.
What cranial nerve is affected in Bell's palsy?
Correct Answer
C. Seventh cranial nerve
Explanation
CN VII, the Facial nerve