ee TOPZERANK REVIEW ACADEMY Chapter V Medical-Surgical Nursing 40, ‘The cllent with idiopathic thrombocy the nurse why its necessary to tak best response? a Steroids destroy the antibodies ytopenic purpura ITP) asks steroids, Which the nurse's nd prolong the life of platelet Steroids netraine the antigens seri eens and prolong thie of ce Rerois increase phage ®b0eyoss and increas he feo platelets, ‘melteot a Se ae the pee: srecpion of pees an increase the life of platelets. uo ‘Success is not measured by what you accomplish but by the ‘opposition you have encountered, and the courage with which you have maintained the struggle against overwhelming odds. + Orison Swett Marden Sees 1. Daniel who has suffered head injury must receive mannitol (Osmitrol by LV. push. n evaluating the effectiveness ofthe drug, the nurse should expect that mannitl shoul 2. decreased cardiac workload b._ increased cerebral circulation increased lung expansion 4. decreased cerebral edema 2. Mikee who experienced a stroke and developed left-sided paralysis is learning how to dress independent. What is the proper technique for upper extremity dressing? 13. _ Requesting help because this activity is impossible to do independently Placing the affected arm inthe shirt before the unaffected Buttoning the shirt frst then flipping ton over the head Placing the unaffected arm in the shir before the affected 3. Apatient who recently experienced stroke tells the nurse that he's experiencing double vision. Which ofthe following nursing intervention is the most appropriate? ‘Turn out the lights the room ‘Instill artificial tears © Encourage the client to close eves 4. Alternately patch one eye every 2 hours accident requires 3 4. Antonio who recently had cerebrovascula rh ‘the ‘ane to ambulate. When providing teaching about cane use, ‘ationae for holding a cane on the uninvolved sie sto: a. maintain stride length prevent edema © prevent leaning 4. distribute weight away from the involved side \Wnen performing nursing assessment, the nurse identifies the following signs and symptoms: impaired coordination, decreased ‘muscle strength, limited range of motion, and the client's Feluctance to move. These signs and symptoms suggest which nursing diagnosis? 10. u. 2, a. jsturbed sensory perception b. Deficient knowledae c. Health-seeking behavior &. Impaired physical mobility tient and notes Brudzinsk' sign and Nurs aan aes gh of whieh ofthe fllowing Kern's sign. These are two lassie alvocders? a. Selzure disorder Parkinson's disease Br Cerebrovascular acldent (CVA) Meningitis ‘a client with an acute head injury. begin for rehabilitation. When ; what should the nurse do to Nurse suan is caring for Ere, ‘The clients stabilized and ready £0 transferring Eric from his bed toch censure client safety? 2. Lock the brakes on the bed Place socks on the client's feet Raise the side rails on both sides of the bed Position the chair approximately 2 (0.6 m) from the bed b. 6. “The nurse is administering neostigmine to a myasthenia gravis patient. Which nursing intervention shoulé the nurse implement? B schedule the medication before meals. Administer the medication for complaints af muscle weakness or difficulty swallowin c._ Give the medication on an empty stomach. GL. Warn the client that hell experience mouth dryness. Nurse Juan should instruct Angelo with Parkinson's disease to avoid which ofthe following activities? 3. Walking tothe car on a cold winter day b. sitting on the beach in the sun on a summer day Walking in an indoor shopping mall 4. Sitting on the deck on a cool summer evening When caring for a patient with a nursing diagnosis of impaired swallowing related to neuromuscular impairment, the nurse should ascertain which of the following nursing care? a. Encourage the client to remove dentures. b. Encourage thin liquids for dietary intake. Position the client in a supine position. 4. Elevate the head of the bed 90 degrees during meals ‘Nurse Juan is teaching family members of Tanya a client with concussion, about the early signs of increased intracranial Dressure (ICP). Which of the following manifestation is considered as early sign of Increased ICP? Inability to wake the patient with noxious stimuli '. Dilated pupils that don’t react to light & Decreased systolic blood pressure 4d, Headache and vomiting ‘The nurse is caring for a patient with brain tumor and increased Intracranial pressure (ICP). Which of the following nursing Interventions should be included in the care plan to reduce ICP? 2. Administer stool softeners. b. Provide sensory stimulation. Scanned with CamScannerXIN REVIEW AC ADENY Chapter V Medical-Surgical Nursing the bose na Clem with his head turned toward the side of 33. The nurse is i Te RreParing cient with systemic upus erythematous "Be. Which ofthe following instruction should the de in the teaching plan? Monitor body temperature. Corticosteroids may be topped when symptoms are S,_ ExPoture to suntght wi help contro skin rashes ‘There are no activity imitations between fare-ups. 24. Immediately following cerebral aneurysm rupture, the patents ‘usually complains of: photophobia b.hemiparesis, 4 explosive headache 15. Jenny Kyler, age 25, suffered from cervical facture requiring Immobilization with halo traction. When caring fora patient in halo traction, the nurse must 2. Encourage the patient to use a pillow under the rng 1b. Remove the brace so thatthe patient ean shower, Keep a wrench taped tothe halo vest fr quick removal i cardiopulmonary resuscitation is necessary . Remove the brace once a day to allow the patient to rest 116. r. Ronald Harry, a chemist, sustained chemical burn on one eye. ‘Which nursing intervention takes highest priority for Or. Harry witha chemical Brn on the eye? 2. Immediately instil a topical anesthetic, and then irrigate the eye wth saline solution b. Administer antbiois to reduce the rsk of infection. Patch the affected eve and call the ophthalmologist. 4. Administer a cyloplegic agent to reduce ciliary spasm, 117. Which ofthe followingis the most common cause of embolic brain injury? a. Asia bilation b. Skull fracture Persistent hypertension 4. Subarachnoid hemorrhage 418. A patient with an exacerbation of her chronic systemic lupus erythematous (SLE). She gets angry when her cll bell Isn't answered immediately. The most appropriate response to her would be: 2, “Would you lke to talk about the problem with the nursing supervisor?” b.“Ican see you're angry. come back when you've calmed down” ©. "You seem angry. Would you like to talk about it?” 4d. “Calm down. You know that stress will make your symptoms 419, Cherie is admitted to the’ hospital for a brain biopsy Nurse Juan knows that the most common type of primary brain tumor: a, Hemangioblastoma & Meningioma b. Glioma 4. angioma 20. a. 2 23, 24, 2s, 26, 2. “The nurse observes that a decerebrate posture isa comatore Theat’ response to painful stimu. The client manifests extengey crete ated arms, exed wsts with palms fing backward any ‘igi Iegs extended with plantar Mesion.Decerebrate posturing yy ‘response to pain indicates: 2. dysfunetion in the brain stern dysfunction Inthe spinal column {ysfunetion in the cerebrum the risk of Increased Intracranial pressure (ICP) ‘The nurses caring fora cant who requires ICP monitoring. ax ‘nurse, you should be alert for what major complication of ice monte? on Bood presure coms Bones & nfetion Fauna Wilson sufered cerebrovascular accident thateft her unable to comprehend speech and unable to speak. The type of aphasa is: 2, Global aphasia Receptive aphasia, . Conduction aphasia 6. Expressive aphasia ‘Nurse Juan is caring for John with an acute head injury. Which of the following nursing diagnosis should Nurse Juan give the highest, priority? 2. iskfor infection b, Ineffective airway clearance & Deficient fluid volume 2. Ineffective tssve perfusion: Cerebral ‘patient with conductive hearing loss caused by otosclerosis and has repeatedly refused to have surgery. To facilitate communication ‘ith the patent, the nurse should utlize the technique of: {stand infront of alight or window when speaking. b, say the client's name loudly before starting to talk. ._sitorstand infront of the client when speaking. 4. use exaggerated lip and mouth movements when talking. Maxis suffering a head injury andis diagnosed to have an increased ICP. Which of the following types of drugs might be elven to control increased ICP? a, Antichotinergies Histamine receptor blockers &Barbiturates 1d, Carbonic anhydrase inhibitors ‘Tovassess the cranial nerve function, the nurse should a, assess arm driting b. assess gag reflex © assess hand grip 4, assess orientation to person, time, and place Joseph, an elderly cient, may have sustained skull fracture after slipping and fating on an ey sidewalk on his way home. NUE Juan knows that basilar skull fractures: Have no characterise findings '. Are always surgleally repair Are the least significant type of fracture 1d. May cause cerebrospinal fui (CSF) leaks from the nose oF Scanned with CamScanner28. 2. a 32 2. En ee Apatient witha di agnosis of m ening caused by Neleseria ‘meninglides. The nurse shout a el Institute which type of elation Br airbore precaution . 2. Standard precaution 5. Secon rope precaution ce. Which clinical finding indicates that A . sustained head Injury? stambrose b. Rapid respiratory rate aes Widening pulse pressure sar ss rw following activities is permitted? ee 2 Gene ‘The nutse is caring for a patient diagnosed with cerebral aneurysm ‘who complains of severe headache. Which action should the nurse perform? 2. Inform the nurse-manager. ._Callthe physician immediately. ¢_Sitwith the cient fora few minutes. Administer an analgesic. “The nurses caring for 2 patient with a diagnosis of myasthenia ravi Which ofthe following situation fr the patient would be wrest appropriate for procedures and care to be completed? In the morning, with frequent rest periods Before bedtime, to promote rest ‘Alt one time, to provide a longer rest period Before meals, to stimulate her appetite a 4 he nurses caring for an unconscious cent. Which using rerentom should the nurse give highest lor? peerfitnga nasogastric (NG) ube nace 1. Administeringan enema cally Inserting an ndweling unary catheter Maintaining a patent airway patient who has suffered a C5 spinal cord contusion that aa a pig tem plavngootal. H#mtet sv reine caicu on dys after the injury has ocurred. When You St down totelkto her, she asks whether her son will ever Pay football again. Which of the following | responses would be best? 1 Reflect on howe she's feeling, and encourage her to express ater fears that she has about is ilu 8. apa tha you are sure, but you wil call the physician to tact her ight 2¥0y &_eassure hr that given time an te normal function. 4. Advise her that it isn'tin his best Interest for her to be so ‘pst and enpain the importance 0 HPP". 1d motivation, he will return 2%. 36 7. 38 33, 40, a. gto actent wth an acutenend iy Wat ture mr postin fr this cent? the est oe nes ar Cee 2 Prone, with me gon, with boy stg Tenant bent pane end of bed Sn Ea ee emhirenetrned ae Har cent has been dlagnosed 10 have Mrctan's ordersindude one 4°00 cn eve every 6 hours. Marta i the need for medication ve problem. Which of doce Symtoms of an eve prviem. vr agnoses would be best oF CoCo? Sito a new health problem ted ta the need for medication Sto refusal to use e722"0P5 roto the disease cocoa syria ‘he oS egaucoms. The oh [Pilocar) 1% in 9% Cresson aoe theotouing fay ea nooy ade Sectmplonce rele sore inontecge enplaints of weakness, incoorination, wre The diagnosis is multiple sclerosis toss Geliowing signs and symptoms, dicovered el phystealasvessment, a 2/pcal of MS? cringe eso, inten erat, ard uninany Reson a ctv abdominal fers and story of nseas apuodic paresthesia in both leas anor story of increased fatigue, and decreased or bsent deep tendon reflexes 4. Resor spasm, conus and negative Babinsts refer itted with co ‘patient ad f oss of balanc dizziness, 2nd (ms). which of during the history jing that her headaches are occurring taking medications. Patients with 2 ‘avoid which of the ‘cynthia Knowles compa more frequently despite Iistory of headaches should be taught to following foods? a, Skim milk b. Chocolate cc Freshly prepared meats Citrus fruits 1 status examination on a patient “The nurse is performing a mental who's dagnosed with a subdural hematoma. This test primarily assesses a. cerebral function c.cerebellar function i sensory function ._ intellectual function ‘Adams diagnosed to have a retinal detachment, Which of the following nursing intervention is most critical for Adam? ‘a, Referring him to an ophthalmologist b, Preparing him for surgery ©. Admitting him to the hospital on strict bed rest 4. Patching both of his eyes movement and the patient should receive early referral to an ophthalmologist '8 64-year-old female is found lying on the floor of her house. She had apparently fallen and hither head on the bathtub. On admission to the neurologic unit, she has decreased level of consciousness, The physician orders positioning as follows: elevate the head of the bed; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion. Which of the following isthe best rationale for this positioning? 2 To prevent flexion contractures b. To prevent aspiration of stomach contents Scanned with CamScannerChapter V q Medical-Surgical Nursing & Todecresse 4 Toavoidimpedingvenaes eee 42. Many men arY men wh sue pnal ues conte tbe tay SetNs The eachngpiantoraimonnthsmpnsecdinioy ‘ould incudesenty concen Which the eles es ould mo iay prevent ereton and ooesnn bo ao 43. Nurse Juan asks a patient's husband ithe understands why his ‘wife is receiving nimodipine (Nimotop), since she suffered cerebral ‘aneurysm rupture. Which response by the husband indicates that hhe understands the drug's use? 3. *Nimodipine reduces the brains demands for oxygen.” b. "Nimoslipine reduces vasospasm in the brain.” © "Nimodipine replaces calcium.” 4. Nmodine promotes growth ofthe blood veses inthe 444, tis a cerebral hemorrhage located within the brain. iis called a, extradural hematoma © subdural hematoma b. epidural hematoma cerebral hematoma 45. Although Ms. Vilar has a spinal cord injury, she can sil have sexual intercourse. Discharge teaching should make her aware that: 2. Positioning may be awkward b. Shean stil get pregnant & She must remove her indwelling urinary catheter prior to Intercourse 4. She can no longer achieve orgasm 46, About 4 hours after Raymond who experienced a stroke is hospitalized, Nurse Manuel obtains these vital signs: blood pressure, 170/80 mm Hg: apical pulse, 58 beats/minute with a regular rhythm; respiratory rate, 14 breaths/minute; axilary temperature, 101 F (38.3 C). Which nursing intervention is most appropriate at this time? a, Assess the client for an over distended bladder. Assess the client for signs of over hydration. Call the physician to report the vital signs. d. Assess vital signs more frequently 447. Orthostatic hypotension is a common problem for spinal cord injuries at the level aa « b. 7 a st 448, Louie was asked by his teacher about the different kinds of shock. ‘The shock that he needs to identity isthe loss of autonomic nervous system function below the level of the lesion. Hes correct if he answered: a. Neurogenic «Cardiac b. Septic d, Hypovolemic re doulureussorde of hich arial ners? on «Seventh 50, Nelia has myasthenia gravis. She wil undergo a surgical intervention that an cause substantial remission of Vay, lof surgical intervention is this? ing 2. myomectomy b. splenectomy © thymectomy 4. esophagostomy Success or failure depends more upon attitude than upon cap, ‘Successful men act as though they have accomplished or ae ‘enjoying something. Soon It becomes a realty. Ac, ook, {eel successful, conduet yourself accordingly, and you will be amazed at the positive results, = Willam James Ene eens Following an accident of John was rushed to the hospital when 1 ray demonstrates a fracture in which bone has spinteres nc several pieces, that fracture is described as a. Comminuted Compound b. Simple 4. Greenstick 2. AT Lyearold woman asks the nurse the difference between ‘osteoarthritis (0A) and rheumatoid arthritis (RA). Which ressone Is correct? 2. Of affects joints on both sides of the body. RAis usally unilateral. (OA is more common in women. RAs mare common in men. (OA is anon-inflammatory joint disease. RAs characteris by inflamed, swollen joints. 4. ORand RA are very similar. 3. When caring fora patient with an acute gout atack, the nur anticipates administering which medication? prednisone (Oeltasone) ——&._ allopurinol optim) b. ASA (Aspirin) . colchicine 4, Which among the following would the nurse identify asthe ‘neurotransmitter responsible for muscle contraction? a. Dopamine & Acetylcholine b. Norepinephrine d. GABA, 5. Afracture's known as “pathologic” when the fracture is characteried by: ‘Presents as one sie of the bone being broken andthe the side bent . Involves damage to the skin or mucous membrane © Occurs through an area of diseased bone 4d. Results in a pulling away of a fragment of bone by liga fr tendon and ts attachment 6. Of the following techniques, the best one for the nurse t0 use when moving a patient's wet casts to handle it with a. Sling made of gauze Fingers b, Palms of hands d, Gloved hands oss 1e nurse Is caring for an elderly female client with ote0re 7. _Themnurs scaring fora elderyfemate cent with st0Fo 4, When giving health teachings to the patient, the nurse: Information about which major complication? a. Third b Fifth 4. Eighth Scanned with CamScannerLUPSRAINN REVIEW ACADEMY Chapter XII Answer Key and Rationales to Questions Section 23 - Neurology 41, Daniel who has suffered head injury must receive mannitol (Osmitrol) by LY push. In evaluating the effectiveness of the dug, the yng ‘expect that mannitol should D. decreased cerebral edema. Ratfonale: Mannitol, an osmotic diuretic, Is used to decrease cerebral edema in clients with head injures. Socratic Approach: Recall the classification of the drug would lead you to the correct option. ‘Mikee who experienced a stroke and developed left-sided paralysis is learning how to dress independently. Whats the proper techrigu extremity dressing? ° 8, Placing the affected arm in the shirt before the unaffected arm ‘Rationale: By placing the affected arm in the shirt fist, the unaffected arm is free to pull the shirt around to the other side and put theca, sleeve on, ‘Socratic Approach: Consider the words used in the question. Usually the answer is on the opposite choices. Read the choices carefuty, 3. Apatient who recently experienced stroke tells the nurse that he Is experiencing double vision. Which of the following nursing intervention, ‘most appropriate? D. Alternately patch one eye every 2 hours. Rationale: Reduces discomfort felt by the client. ; Socratle Approach: Eliminate first those choices that would not help solving the double vision. 4, Antonio who recently had cerebrovascular accident requires a cane to ambulate, When providing teaching about cane use, the rationale for holding a cane on the uninvolved side s to: D. distribute weight away from the involved side. Rationale: Holding 2 cane on the uninvolved side distributes weight away from the involved side. Socrotie Approach: First eliminate those that are obviously fa from being the answer. Those choices that sounds more scientifically and rational are often the correct answer when performing nursing assessment, the nurse identifies the following signs and symptoms: impaired coordination, decreased muscle se limited range of motion, and the client's reluctance to move. These signs and symptoms suggest which nursing diagnosis? D. Impaired physical mobility Rationale: Impaired physical mobility isa imitation of physical movement that’s identified by the characteristics found in ths client. Socratie Approach: Sometimes the key words on the questions implies the answer, Find In the options those that can be the same with ‘coordination, mation and movement. ‘Nurse Juan is assessing a patient and notes Brudzinski’s sign and Kern’ sign. These are two classics sighs of which ofthe following disorders? ‘Rationale: a positive response to one or both tests Indicates meningeal iritation that Is present In Meningitis Socratic Approach: Recall that this are signs of MENINGEAL irritation, 7. Murse Juan is caring for Eric, a client with an acute head injury. The client is stabilized and ready to begin for rehabilitation, When transfering from his bed to chair, what should the nurse do to ensure client safety? en fotcenanination. Whe £4 ‘A. Lock the brakes on the bed Aotinote: Locking the wheels ofthe bed (and wheelchair, Ione used) wil prevent the bed (and chat from sling away, thus preventing Socratle Approach: ifthe question Is procedural ike this always try to Imagine each options whether It would be correct or not 8. The nurse is administering neostigmine to a myasthenta gravis patient. Which nursing ia z Dt eceeitie Oa mca emer ae sing intervention should the nurse implement? Rationale: Because Neostigmine’s onset of action Is 45 to 75 minutes, t should be administered atleast 45 chewing and swallowing, Taking neostigmine with a small amount of food reduces Gl adverse ifort consistent blood levels ostgmine must be given ee EE Ee Scanned with CamScanner utes before eating to improve ects of the medication at Scheduled times to ensureMN, Chapter XII ; Answer Key and Rationales to Questions Section 23 - Neurology Socrotle Approach: First identify the eau the Interventions when giving the dug. Saute eear er en 5 F minutes also consder such. In MG, there ts may require energy 28 well asthe drugs aso intended to improve swallowing and chew. 8, Nurse Juan should instruct Angelo with Parkinson’ activities? Ostia on he bese ee th Pains at toad wh fthe ao ‘ona summer day jonale; of hyperthermia and should be Rationale: The patient with Parkinson’ disease may be hypersensitive to heat, which increases the risk of hyperther instructed to avoid exposure to hot weather arena Socratic Approach: Analyze the options some of tham are almost the some, Often the answer Is opposite of those choices UAE 9PPEAY SIGE irment, the nurse should ascertain whi 30, When caring for a patient with a nursing diagnosis of | Impaired swallowing related to neuromuscular impairment, th se of the following nursing care? D. Elevate the head of the bed 90 degrees duting meals. Rotionole: The head of the bed must be elevated while the client Is eating, Te client shouldbe placed Ina recumbent position not 2 supine pasion, Socratic Approach: Imagine the ways on how to prevent aspiration, Eliminate those choices that would cause aspiration otherwise 11, Nurse Juan is teaching family members of Tanya a client with concussion, about the early signs of increased intracranial pressure (ICP). Which of the fllowing manifestation is considered as early sign of increased ICP? 0, Headache and vomiting Rotionale re early signs of increased ICP Socratic Approach: Take note of the word early, Analyze the options and classify them whether itis an early or late sign. Detractors here are: late signs. 12, The nurse i caring for a patient with brain tumor and increased intracranial pressure (CP). Which ofthe following nursing Interventions should b included inthe care plan to reduce CP? A. Administer stoo! softeners. Rationale Stool softeners reduce the risk of straining during a bowel movement, which can Increase ICP by ralsing intrathoracic pressure and interfering with venous return, Socrtie Approack: Rcal al postions and actions that cn increase ICP. you see them onthe options eliminate them, they are often the dietracers not the answer 13, The nurse is preparing client with systemic lupus erythematous (SLE) for discharge. Which of the following instruction should the nurse include in the teaching plan? A Monitor body temperature. Rationales Fever ean signal an exacerbation and shouldbe reported tothe physician, Fatigue can cause a ore-up of SLE Socrotle Approach: Recall the dsease proces of SLE, Gt some keywords In the cholees and eliminate those that are incorrect fst. Beware of the statements, cstracters ae often stated in the vay ts opposite of what shouldbe correct, 14, immediately following cerebral aneurysm rupture, the patents usually complains of: D, explosive headache Rationale: or “the worst headache I've ever had” Is typically the first presenting symptom of a ble: space in the intracranium that compresses the brain ding cerebral aneurysm that occupies Socratic Approach: Analyze the options detractor are late signs. Eliminate them first. 15. Jenny Kyler, age 25, suffered from cervical fracture requiring immobilization me age 25, ‘with halo traction. When caring for a patient in halo traction, the nur © Keep a wren ve alo ves for quick removal if cardlopulmons Pa wrench tped tothe hal 4 ‘ardlopulmonary resuscitation is necessary Ratlonate. The nurse must have awrench taped onthe vest at ll times fa Imes for quick halo remou Socratic Approach: Always consider the safety of the patient. ulek halo removal during emergency situation TOP RANK REVI Scanned with CamScannerPN SS neview anne” _ Chapter XII ; Key and Rationales to Questions Section 23 - Neurology intervention takes highest priority for Or. Hare ith hen Answer J burn on one eve. Which nursing chemist, sustained chemical then irrigate the eye with salir cen the PH of the eye should be checked, be Ronald Harry, 2 burn on the eve? ‘A lmmediately in x ye solution. still a topical anestheti Irrigation should be continued wy nt Fauld be done for 5 - 10 minutes and th Fationale:rigation 3 done tors rte eve isrestored to neutral Pitot ees restored to neu neal should be neutralized or removed ist before PU ‘Socratic Approach: Remem the following Is the most common cause of sting any medication. First aid is. brain injury? 7, Whichoft embi A. Arial ibilation Gajoy by traveling cot may result from ara brilation, Blood may poolin the fibilating atrium and canbe relesy artery to the brain Rationale: An embol to travel up the cerebral ‘Socratic Approach: Recall that embolism Is for 1g to clot formation. med when theres stasis ofthe blood, Analyze the options what condition can cause lend stasis lea patient with an exacerbation of her chronic systemic lupus erythematous (st) She Gets 208 when her cal bell isn’t answered immedi, ‘The most appropriate response to her would be: C."You seem angry, Would you like to talk about it 18, 12” in which the nurse acknowledges what the cient ferstand its cause and begin to deal witht. ing the feeling of the patient is therapeutic Tationale: Verbalzing the observed behavior is a therapeutic communication techniaue i fealng. Offering to listen tothe client express her anger can help the nurse andthe client une “Socrotic Approach: Take note of the words used in the responses and remember that recog Te. Cherieis admitted to the hospital for a brain biopsy. Nurse Juan knows that the most common type of primary Brain tumor 8B. Glioma “Rationale: account for approximately 45% of brain tumors ‘Socratic Approach: Recall the concepts about brain tumor. ‘The nurse observes that a decerebrate posture is a comatose client's response to painful stimuli, The client mar Fexed wrists with palms facing backward, and rigid legs extended with plantar flexion. Decerebrate posturing as a response to pain indicates {A dysfunction in the brain stern, 20. 21. The nurse is caring fora client who requires ICP monitoring. As a nur Rrcegeae 1g. AS a nurse, you should be alert for what major complication of ICP monitor's? Rationale: The catheter for measuring CP is inserted through a burr hole Int a Redooae 8 rted through a burr hole nto a lateral ventricle of the cerebrum, thereby creating 2risko! Socratic Approach: Recall how do we measure the ICP an ee Secret Ae 1e ICP and the possible complication of it, Complication differs from the actual signs of 22. Fauna Wilson suffered cerebrovascular accident that left vu Witon " that left her unable to comprehend speech and unable to speak. The type of aphasia Rationale: occurs when all anguage functions are affected Socratie Approach: Commonly aphasia affects only one Ql ne domain deficit iy one domain, Elminate options referring only to one domain defi 23. Nurse Juan is caring for John with an acute head Injury, 2. Ineffective alrway cea Which of th iy denevace following nursing diagnosis should Nurse Juan give the highest ori? Fattonale: EbIsting 3 patent aowayalvay kes pr Socratic Approach: Consider ABCs in prioritizing. mony Scanned with CamScannerms B TT TOPZERANK Chapter XII : Answer Key and Rationales to Questions Section 23 - Neurology ‘Apatient with conductive hearing loss caused pes tohme gee 19 BESS patent the nurse shoul the ecu cf nent a at eens Ester andin ont of he dent whee weg. Soot fer coo whats [aoe ‘Standing directly i front of a hearing-impaired dient allows him to ip-ead and see facial exPress im ing saic . ices which among ten Socratic Approach: Analyze that ip reading is the next way for them to communicate and understand. lect ths eh ° feboit mae ear : of drugs might! ‘Maxis suffering» head injury andi diagnosed to have an increased ICP Which of the following types of &7¥85 5 10? 0. Carbonic Anhydrase Inhibitors patent wth increase IC. Tis decreases cortal otionole: Carbonic anhydrase inhibitors (e.g, Acetazolamide) may be used to induce coma in Ne rece fo goose md acivity and cerebral metabolism, reduces cerebral blood volume, decreases cerebral edema and reduces Fast obvious no effect on ICP. Socratie Approach: Recall the drug mechanism ofeach option and try torelateit to ICR Eliminate those that a8 Ob) 2. ‘To asses the cranial nerve function, the nurse should B. assess gag reflex. ‘ational: The gag reflex is governed by the glossopharyngeal nerve, one ofthe eranial nerves. Socratic Approach: Recall the 12 cranial nerves and ther functions. fone of them is include in the choices might as well Its the answer 2. Joseph, an elderly client, may have sustained stl fracture after slipping and fling on an icy sidewalk on his way home. Nurse Juan knows that basilar skull fractures: D. May cause cerebrospinal fluid (CSF) leaks from the nose or ears, ‘Rationale: a basilar fracture carries the risk of complications of dual tear, causing CSF leakage and damage to cranial nerves Il, VI and Vill {lassie findings in this type may include otorthea, rhinorrhea, Battle’ sign and raccoon eyes. Secrotic Approach: Recal the concepts about basilar fracture. 2. ‘Apatient with a diagnosis of meningitis caused by Neisseria meningitdes. The nurse should institute which type of isolation precaution: . Droplet precaution 2 x0 an eure scaring fora patient dig Retionole: Ths cent requires droplet precautions because the organism can be transmitted through airborne droplets when the dient coughs, sneezes, or doesn't cover his mouth. Secatc Approach: Recall the mode of transmission of bacterial meningitis would lead you tothe type of precaution that can be applied. “Ambrosi, who was injured during a car accident in SCTEX, is brought to the emergency dey ‘Which clinical finding indicates that Ambrosio sustained head injury? B.Widening pulse pressure Partment of ose 8. Lingad Hospital by ambulance. Retionale: As intracranial pressure increases following a head injury, the 3 the difference between systolic and diastolic blood pressure increases, Seeratc Approach: Recall that in head injury there is increase ICP with si toll blood pressure rises, Widening of pulse pressure occurs as igns termed as Cushin {_snébradypna} iinat the choices thats oppose ofthese triad (Widened pulse pressure, bradycardia. A patients isbeing discharged after successful same-day cataract surgery. The sates ten es een nurse instructs the patient Cee tus aveded. Which ofthe allowing cies i permite "Patient about which activities can he perform and Retionole:C ‘ooking won't cause increased intraocular pressure, Soong Cooking won't cause pressure, proach: Always asthe question which would nat increase intraocul ocular pressure? 250d with cerebral anus ll the physician immediately. —_ “Orlin of severe headache. Whi 'adache. Which dtion should the nus nurse perform? MM Scanned with CamScannerTOPSRANK REVIEW ACADEMY Chapter xi | ionales to Questions Answer Key and Rati Section 23 - Neurology Saeuram is Teakng. The nurse oud at he pul been a Rationale: The headache may be an indication thatthe ‘would direct you tothe 2 Socratic Approach: Recall what does severe headache signifies ine patient would Be Most appropri consideration. seni ravi wich fe ftlowing Suan? fort 32, The nurse is caring fora patient witha diagnosis of myas for procedures and care to be completed? ‘A Inthe morning, with frequent rest periods Faracierved by etreme muscle weakness which anary worsens after efor and improves with ret, I copessing weakness within 08 OOF “Rationale: Myasthenia gravis disease process of M st priority? Socratic Approach: Consider the ould the nurse give hehe dient. Which nursing intervention 5! 33, The nurse searing for an unconscious . Maintaining 2 patent airway Fninga patent airway always takes toP Pr fer ABCS in prioiiing. jority. vr pavingfootbal His mother frying inthe wagon ne ever play football again. Which of the folowing ‘Rationale: Mainta ‘Socratic Approach: Consid suffered a C5 spinal cord co has occurred. When you si sd encourage her to express other fears tha mtusion that resulted In quadriplegia fo! Fedowrn to talkto her, she asks wheter her 50 34, Apatient who has ays after the iniury responses would be best? ‘reflect on how she's feeling st she has about his injury. Thar fecingy wie most herpetic and wil allow the nurse to gather more data about er to expres 1 those first that sound not therapeutic. ational: listening and encouragi the mother’s understanding ofthe iu caer pooch: ways consider therapeutic communication, Ema caring for a cient with an acute head in ‘ith the head of the bed elevated ~ an the head ofthe bod elevated, reduces the rik of airway occlusion by the tongue and aid id may aso reduce intracranial pressure. ‘and reduces ICP 35. Nurse Juan's jury. What is the best position for this cent? Gonhis side, jent on his side, sa | se head of the be ‘Rationale: Positioning the cl promotes patent airway the drainage of secretions. Elevating th “Secrotic Approach: Remember to consider whether it rat has been diagnosed t0| verbalize that he 1g diagnoses would be best for Coco? Ys orders include one drop of pilocarpine (Poe) ‘thave symptoms of ne 36. Coco 2 55-year-old male cle have open-angle glaucoma. The physi {isin each eye every 6 hours. Martin "Joesn't understand the need for medication because he doesn’ ‘ofthe following nursin enn enone Approach: sometimes the question already imple the answer Hedge to manage a condition. J plored vision, intention tremor, and urinary hesitancy para typical of nase; ti ne vision, ly sign of MS, ass Intention tremor (tremor when performi Saar ‘Rationale: Nerve damage can cause urinary hesitancy. Socratic Approach: Analyze each symptoms on the choices, Ifyou ces Ifyou find one that makes the statement incorrect then eliminate that option. | 38. cynthia Knowles complains that her headaches are occuring mi should be taught to avoid which ofthe fl ere the following foods? medications. Patients with a history of headaches Chocolate ‘ationale: They should be taught to keep a food dla ight to keep a food dlary to identify potential triggers, Typical headach cal headache triggers include alcohol, 3 lude alcohol, aged cheese’, processed meats and chocolates and caffeine contain ces ine containing products, ‘Socratic Approcch: Recall foods that could trigger headache. Often these are th ese are those containi aining catfeine, 39, The nurses performing a mental stat 1s examination on a Patient whois diagnos 'gnosed witha subdural hematoma, This t ma, This test primarily assesses A cerebral function. Scanned with CamScannerTOPSRARS Chapter XII . ' Answer Key and Rationales to Questions Section 23 - Neurology ‘ttention span, ‘atlonole: The mental status examinati judgment, and abstract reasoning. Secratle Approach: Recall the parts ofthe brain and theie specific funtion. se are orientation, ion assesses functions governed by the cerebrum. some of the csitical for Adam? 40, Adem |s diagnosed to havea retinal detachment. Which ofthe following nursing intervention Is most Admitting him to the hosptal on strict bed rest, ‘Rationale: immediate bed rest is necessary essary to prevent further injury Secratie Approach: Consider the client's condition and the things that might aggravate the condition. ‘the bathtub. On admission to the we head of the bed; keep the head 41, A 64syearold female is found Iying onthe floor af her house. She had apparently fallen and hither head oh pest rationale for this positioning? elevate th neurologic unit, she has decreased level of consciousness. The physician orders positioning 2 follows: eleven in neu alignment with no nec exon or hes rotation; aol sharp hip flexion. whieh ofthe flowing "Me . To avoid impeding venous outfiow ed volume inside the skull and Rationale: Any activity or postion that impedes venous ouiow frm the head may contribute a increased volume possibly increase intracranial pressure. eae ao Socratic Approach: When the head is avelved always consider the intracranial pressure. Review Monrokalie coculo® TET TO, Increase in the contents ofthe stl (the brain, blood andthe CSF) would increase the ICP since skull i 50 Hi cord injury should include sexual 42, Many men who suffer spinal njres continue tobe sexualy active. The teaching plan for aman with a splnal cord injury should oy concerns. Which ofthe folowing injuries would most likly prevent erection and ejaculation? sé Rationale: Men with spinal cord injury should be taught thatthe higher the level ofthe lesion the better thelr sexual function will Be. The sacral region is the lower area on the spinal column and injury tothe area will cause more erectile dysfunction. Socratic Approach: The lower the affectation the greater the rsk thatthe sexual function are affected. 43, ‘Nurse Juan asks a patient ’s husband if he understands why his wifes receiving nimodipine (Nimotop), since she suffered cerebral aneurysm rupture. Which response by the husband indicates that he understands the drug's use? 8. "Nimodipine reduces vasospasm in the brain” ‘atlonale: Its calcium blocker that acts on cerebral blood vessels to reduce vasospasm. Socratic Approach: Ifthe question is about drug always recall its mechanism would lead you to the correct option. 44, tis a cerebral hemorrhage located within the brain. Itis called D. cerebral hematoma Rationale: An intracerebral hemorthage, or bleeding into the brain tissue, is most common in patients with hypertension and cerebral atherosclerosis, because degenerative changes from these diseases cause rupture of the blood vessel Secratie Approach: Keyward: Cerebral hemorthage = Cerebral hematoma 4. although Ms. Villar has 2 spinal cord injury, she can stil have sexual Intercourse Discharge teaching should mal She can still gt pregnant ig should make her aware that: Rationale: Women with spinal cord injury who were sexually active maj ‘an still become pregnant. She may be capable of achieving orgasm, crete Avpronc Racal he concepts of inal crd nur and anajethe options Often when there is opposite options one of them is corcect. "continue having sexual intercourse and must be reminded that they 45. About 4 hours after Raymond who experienced a stroke Is hospitalze apical pulse, $8 beats/minute with a regular rhythm; respiratory rate, Intervention is most appropriate at this time? ©. Call the physician to report the vital signs. 6, Nurse Manuel obtal ins these vital signs: blood pressure, mm Hes tamara € vital signs: blood pressure, 170/80 mm Hg; axillary temperature, 101 F (38.3 C). Which nursing Signs to the physician, Secretie Approach: Recall that this signs are signs of increase, SICP and an abnormal ining. Scanned with CamScannerTOPSRANK 47. 48. REVIEW ACADEMY Chapter XII . Answer Key and Rationales to Questions Section 23 - Neurology Orthostatic hypotension is a common problem for spinal cord injuries atthe level 8.17 with lesions above T7. Rationale: Orthostatic hypotension isa particularly common problem for patients with lesions abo. Socratic Approach: Recall about functional allies by evel of cord injury. Louie was asked by his teacher about the different kinds of shock. The shock that he needs to identify is the loss of autonomic nervous ste function below the level ofthe lesion. He is correctf he answered: A. Neurogenic Rationale: Neurogenie shock develops asa result ofthe loss of autonomic nervous system function below the level of the lesion. | Socratic Approach: Recall the concept about different kinds of shock. 49, Tie dovloureuxis a dsorderof which cranial nerve? Brith Rationale: Wigeminal neuralgia (Tie doulourevs) is a condition ofthe Ath cranial nerve thats charac 1 fith cranial nerve that is characterized by paroxysms of pain in hema erected yan ofthe tree branches, but most commonly the secnd and tid branches ofthe tigeninal rene Socratic Approach: Recall the basic disorders of the cranial nerve, 2 50. Nelahas myasthenia gravis She wil undergo a surgical interven ea 2 sual intewenton that can cause substantial remission oft. What kind of surgical mene © Cothymectomy Rationale: Thymectomy (surgical removal ofthe __ Raat > the thymus gland) can produce anki NF Scanned with CamScanner