how you were graded pn 141 neuro/sensory rebecca maier, bsn december 2014
TRANSCRIPT
How you were Graded
PN 141 Neuro/SensoryRebecca Maier, BSN
December 2014
Quiz 2 – ATI Intro to Pharmacology ModulesHanded out 11/24 due 11/25
Test 2ATI Intro to Pharmacology Test – max take x 3 –Handed out 11/25 due 12/1
Part 1 - 77.3%104”60, 80, 92
Part 2 - 76%84”
153.3÷ 2=
76.6%
92% - P176% - P2168 ÷ 2=
84%
Final
PN 141 Neuro/SensoryRebecca Maier, BSN
December 2014
1. ANS: DThe Snellen Eye Chart tests visual acuity. A vision evaluation of 20/40 means that the patient can see at 20 feet what the person with normal vision can see at 40 feet. PTS: 2 DIF: Cognitive Level: Application REF:AHN Page 608 (T13-2), 609; Review slide 3OBJ: 7 TOP: Snellen evaluation KEY: Nursing Process Step: I AssessmentMSC: NCLEX: Physiological Integrity
a. 10b. 20c. 30d. 40
1. The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 feet what the normal eye can see at _______ feet.
2. ANS: D“Legal blindness” refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have been established to help determine the exact extent of the vision loss and what assistive measures are appropriate for the individual. The nurse will need more information as to the exact extent of the vision loss for this patient. PTS: 2 DIF: Cognitive Level: Analysis REF: AHN Page 607-611 ; Review slide 4OBJ: 6 TOP: Blindness KEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity
a. No vision enhancement techniques would be appropriate for this patient, because he is totally blind.
b. This patient probably has some light perception, but no usable vision.c. This patient has some usable vision, which enables him to function at an acceptable level.
d. Further questioning is needed to determine how this patient’s visual impairment affects his normal functioning.
2. The patient tells the nurse that he is legally blind. This information provides the nurse with which information to use in planning care?
3. ANS: A
Place the neck in a neutral position (not flexed or extended) to promote venous drainage. HOB 30 -45 degrees PTS: 2 DIF: Cognitive Level: ApplicationREF: AHN Page 671 column 2 ; 668 -670 Review slide 27OBJ: 13 TOP: Intracranial pressure (ICP) KEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity
a. Place the neck in a neutral position to promote venous drainage.b. Suction hourly to stimulate the cough reflex.c. Add extra blankets to keep the patient warm.d. Turn the patient frequently to prevent skin impairment.
3. A patient has a head injury and is presenting with signs and symptoms of increased intracranial pressure. Which nursing intervention would be helpful in reducing this pressure?
4. ANS: ATympanoplasty can correct a conductive hearing loss.
PTS: 2 DIF: Cognitive Level: Knowledge REF:AHNPage 644 ; 644-645
Review slide 20OBJ: 17 TOP: TympanoplastyKEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity
a. Conductive hearing lossb. Sensorineural hearing lossc. Congenital hearing lossd. Functional hearing loss
4. What does a tympanoplasty correct?
5. ANS: DCollection of objective data includes a change in level of consciousness. A change in the level of consciousness is the earliest sign of increased intracranial pressure. PTS: 2 DIF: Cognitive Level: Analysis REF: AHN Page 669; review slide 26OBJ: 12 TOP: Intracranial pressure (ICP) KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. Pupil changes
b. Ipsilateral paralysis
c. Vomiting
d. Decrease in the level of consciousness
5. What is the cardinal sign of increased intracranial pressure in a brain injured patient?
6. ANS: CHearing improvement will not be noted until edema subsides and the packing is removed. PTS: 2 DIF: Cognitive Level: ApplicationREF:AHN Page 644 review slide 18OBJ: 17 TOP: StapedectomyKEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity
a. A large percentage of stapedectomies are not successfulb. It will take at least 10 days for the graft to healc. Hearing will not return until edema subsidesd. Hearing will improve after irrigation of the ear
6. Four hours after a stapedectomy the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response?
7. ANS: CThe nurse must include patient teaching about opening the mouth when sneezing or coughing or blowing the nose gently on one side at a time for 1 week.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 644 | Patient . Teaching Box; Review slide 18OBJ: 19 TOP: StapedectomyKEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
a. Hourly changing cotton from external ear canalb. Gently blowing both nares simultaneouslyc. Teaching patient to open mouth when sneezing or coughingd. Limiting activities for 3 weeks
7. A patient is scheduled for a stapedectomy. Appropriate postoperative teaching should include which of the following?
8. ANS: ABefore the dye is injected, patients must be asked whether they have any allergies, specifically whether they have had any anaphylactic or hypotensive episodes from other dyes.
PTS: 2 DIF: Cognitive Level: Analysis REF: AHN Page 664 , 115;Review slide 33OBJ: 4 TOP: Diagnostic procedures KEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity
a. Obtain an allergy history before the test.b. Place her in a flat position after the test.c. Warn her that paralysis could result from injection of the contrast medium.d. Keep her NPO for 6-8 hours after the test.
8. A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned for her with respect to this diagnostic test?
9. ANS: BThe American Foundation for the Blind has lists of agencies to assist and educate the visually impaired patient.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 607-610; Review slide 4 OBJ: 15 TOP: Medications KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity
a. American Red Crossb. American Foundation for the Blind for a list of agenciesc. Local hospital social workerd. The public health department
9. When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact?
10. ANS: ASurgical navigational systems are computerized devices that guide the surgeon and make possible the resection of tumors that were once thought to be inoperable.
PTS: 2 DIF: Cognitive Level: Comprehension REF: Video from Power point; Review Slide 37 OBJ: 30 TOP: Hematoma KEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity
a. Computerized devices that guide the surgeonb. A set of detailed anatomic maps pinpointing specific areas of the brainc. A written set of progressive processes for the resection of small brain tumorsd. The use of radioactive materials to pinpoint small tumors of the brain
10. What are surgical navigational systems?
11. ANS: DPhacoemulsification uses ultrasound to break up the cataract.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 617 Col. 2; 617-618f . Review slide 6 OBJ: 11 TOP: Infectious/inflammatory disordersKEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity
a. “Drying” the cataract with hypertonic salineb. Removing the lens through the anterior capsulec. The insertion of a new lensd. Breaking the cataract with ultrasound
11. What does the cataract treatment of phacoemulsification involve?
12. ANS: DA primary objective of nursing care for the patient with an infectious or inflammatory process of the eyelids is prevention of the spread of infection.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 613-614; Review slide 9 ; Power Point Day 2 – slide 40-43 OBJ: 8 TOP: Infectious/inflammatory disorders KEY:Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity
a. administering antibiotics.b. flushing the eye with sterile ophthalmic solution.c. maintaining bedrest.d. preventing further infection.
12. A patient has an infectious/inflammatory process of the eyelid. The primary goal of nursing intervention is
13. ANS: DMigraine headaches are unusual in that there are prodromal (early signs and symptoms of a developing condition or disease) signs and symptoms that occur before the acute attack.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 665 Col. 1 last Para . Review slide 29OBJ: 9 TOP: HeadachesKEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. They are observed during times of stress.b. They become worse toward evening.c. They have their onset when the person is in his or her twenties or thirties.d. They cause unusual smells or sounds for the patient before the pain begins.
13. A patient has been complaining of headaches. Which of the following would the nurse expect to happen if these were migraine headaches?
14. ANS: ARetinopathy is caused when the capillaries in the retina have aneurysms or hemorrhage.
PTS: 2 DIF: Cognitive Level: Comprehension . REF:AHNPage 618; 526, 618 -620; Review slide 7OBJ: 9 TOP: Glaucoma KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. Capillaries in retina hemorrhageb. Long-term overdosing of insulinc. Retinal detachmentd. Aging
14. What does diabetes retinopathy result from?
15. ANS: DFund of knowledge is tested by questions such as “Who is the president?” or asking about current events.
PTS: 2 DIF: Cognitive Level: Comprehension . REF:AHN Page 658; 658-659, Review slide 23OBJ: 9 TOP: Level of ConsciousnessKEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity
a. Orientationb. Memoryc. Calculationd. Fund of knowledge
15. What is the nurse assessing when asking the patient, “Who is the president of the United States?” during a level of consciousness assessment?
16. ANS: BThe symptoms of painful head, painful chewing, and pain when the auricle is moved all indicate external otitis, frequently caused by compacted cerumen.
PTS: 2 DIF: Cognitive Level: Knowledge REF:AHN Page 635 ; 635-640 PPT day 3 slides 27-31 (30); Review slide 14OBJ: 16 TOP: External otitisKEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. mumpsb. external otitisc. otitis mediad. labyrinthitis
16. The nurse will assess for _____________ when the older adult home health patient complains that the entire right side of his head hurts and he cannot chew without pain .
17. ANS: BFluid restriction, diuretics, and a low-salt diet are prescribed in an attempt to decrease fluid pressure.
PTS: 2 DIF: Cognitive Level: Knowledge . REF:AHN Page 641 ; 641-644 PPT day3 slides 56-65; Review slide 15OBJ: 15 TOP: Ménière’s diseaseKEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological
a. surgery.b. diuretics.c. hearing aids.d. analgesics.
17. Most patients with Ménière’s disease are treated with
18. ANS: AAutonomic dysreflexia occurs as a result of abnormal cardiovascular response to stimulation of the sympathetic division of the autonomic nervous system as a result of stimulation of the bladder, large intestine, or other visceral organs. The most common cause of this condition includes a distended bladder or fecal impaction.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 710 Col.2 Par. 3 | . Page 145-147; 710-714; Review slide 35OBJ: 10 TOP: Spinal cord injuryKEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. bladder distention.b. defecation reflexes.c. postural changes.d. electrolyte imbalance.
18. A patient, age 23, has a comminuted fracture of T6-T7. She has a spinal cord injury resulting in paraplegia. She manifests signs and symptoms of autonomic dysreflexia, which is frequently triggered by
19. ANS: CDrinking alcohol is discouraged while on Ceclor. The drug should be taken in its entirety and stored in the refrigerator. The drug can be taken with or without meals.
PTS: 2 DIF: Cognitive Level: Knowledge REF:AHN Page 637, Table 13-5 Pages 636-638; Review slide 14OBJ: 16 TOP: Ceclor KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity
a. Store suspension at room temperatureb. Discontinue drug when symptoms abatec. Avoid alcoholic beveragesd. Take with meals only
19. What should the nurse advise the 20-year-old to do who has been put on cefaclor (Ceclor) for a resistant otitis media?
20. ANS: DThese are indicators of autonomic dysreflexia or hyperreflexia. It is a medical emergency. The patient should be placed in an upright position to decrease blood pressure and the blood pressure should be checked. Assessments for impaction, full bladder, or a urine infection can help to evaluate this condition.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 712 Box 14-4; . pages 710, 712; review slide 35OBJ: 20 TOP: DysreflexiaKEY: Nursing Process Step: InterventionMSC: NCLEX: Physiological Integrity
a. Place patient in flat position and check temperatureb. Administer oxygen and check oxygen saturationc. Place on side and check for leg swellingd. Sit upright and check blood pressure
20. A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and “goose flesh.” What should be the primary nursing intervention based on these assessments?
21. ANS: DMiotic eyedrops allow the pupil to constrict and open the canal of Schlemm to drain the excess fluid.
PTS: 2 DIF: Cognitive Level: Application REF: AHN Page 625; 623-627 Review slide 8OBJ: 4 TOP: Aging KEY: Nursing Process Step: AssessmentMSC: NCLEX: Safe, Effective Care Environment
a. Dilate the pupil and sharpen visionb. Lubricate and moisten the dry eyec. Irrigate the surface of the eyed. Constrict the pupil and open the canal of Schlemm
21. What do miotic eyedrops do for a patient with glaucoma?
22. ANS: DAccommodation: The eye is able to focus on objects at various distances.
PTS: 2 DIF: Cognitive Level: Application REF:AHN Page 604 (#2); . Review slides 2 and 3 OBJ: 7 TOP: Aging KEY: Nursing Process Step: AssessmentMSC: NCLEX: Safe | Effective Care Environment
a. PERRLA.b. refraction.c. focusing.d. accommodation.
22. When the eye adjusts to seeing objects at various distances, it is called
23. ANS: BPadded side rails may be used, especially if seizures often occur during sleep.
PTS: 2 DIF: Cognitive Level: Application REF:AHN Page 679; . Pages 676-680; Review slide 39OBJ: 10 TOP: Seizures KEY: Nursing Process Step: PlanningMSC: NCLEX: Safe | Effective Care Environment
a. placing the patient in protective restraints.b. being certain padded side rails are present.c. suggesting that the family monitor the patient.d. placing the patient with one-on-one nursing service.
23. A patient, age 27, has been admitted to the neurological department because of seizures of unknown cause. The nurse should take precautions by
24. ANS: BA pressure dressing will be applied to the right eye socket and the dressing should be checked every hour for the first 24 hours.
PTS: 2 DIF: Cognitive Level: Application REF:AHN Page 629; Review slide 11OBJ: 11 TOP: Infections/inflammatory disordersKEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. Turn, cough, and deep breathe every 3 hoursb. Apply a pressure dressing over the right eye socketc. Document dressing assessment every 2 hoursd. Turn on the affected side
24. A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care?
25. ANS: CThe patient’s ear and nose are checked carefully for signs of blood and serous drainage, which indicate that the meninges are torn and spinal fluid is escaping. No attempt should be made to clean out the orifice or to blow the nose. The drainage can be wiped away. The drainage can be tested for the presence of glucose, which would confirm that the fluid is spinal fluid and not mucus.
PTS: 2 DIF: Cognitive Level: Application REF:AHN Page 709; Review slide 25OBJ: 20 TOP: Trauma KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity
a. Cleanse nose with a soft cotton-tipped swabb. Gently suction the nasal cavityc. Gently wipe nose with absorbent gauzed. Ask patient to blow his nose
25. The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment?
a. The procedure will destroy the retina, which is not getting enough blood supply.b. The procedure will reduce edema in the macula of the eye.c. The procedure will vaporize fatty deposits that appear in the retina.d. The procedure will destroy new blood vessels, seal leaking vessels, and help
prevent retinal edema.26. ANS: DPhotocoagulation is useful in diabetic retinopathy to cauterize hemorrhaging vessels and to destroy new vessels.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 630; Review slide 7OBJ: 9 TOP: Diabetic retinopathyKEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
26. How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy?
27. ANS: DPhotocoagulation is useful in diabetic retinopathy to cauterize hemorrhaging vessels.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 630; Review slide 7OBJ: 6 TOP: Diabetic retinopathyKEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity
a. destroy the retina, which is not getting enough blood supply.b. reduce edema in the macula of the eye.c. vaporize fatty deposits that appear in the retina.d. destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.
27. The patient, age 62, has had insulin-dependent diabetes mellitus for 20 years and has symptoms of proliferate diabetic retinopathy. He is scheduled for his first panretinal photocoagulation treatment. The nurse explains to him that the purpose of this procedure is to
28. ANS: BA lumbar puncture is done to obtain CSF for examination, to relieve pressure, or to introduce dye or medication.
PTS: 2 DIF: Cognitive Level: Knowledge REF:AHN Page 661; Review slide 40 Pages 661-662OBJ: 12 TOP: Lumbar puncture KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. Serumb. Cerebral spinal fluid (CSF)c. Urined. Arterial blood gases
28. A lumbar puncture is performed to obtain which specimen?
29. ANS: AChildren’s shorter and straighter eustachian tubes provide easier access of the organisms from the nasopharynx to travel to the middle ear.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 636 Review slide 14OBJ: 16 TOP: Otitis mediaKEY: Nursing Process Step: EvaluationMSC: NCLEX: Physiological Integrity
a. Eustachian tubes in children are shorter and straighter.b. Infection descends via the eustachian tube to the throat.c. Children’s eustachian tubes are more vertical and longer.d. Otitis media is seen equally in both children and adults.
29. Why is otitis media found more frequently in children 6 to 36 months?
30. ANS: BPersons with bacterial meningitis are placed in respiratory isolation until the pathogen can no longer be cultured, usually 24 hours.
PTS: 2 DIF: Cognitive Level: Comprehension REF:AHN Page 704; 704-705 Review slide 40OBJ: 18 TOP: Bacterial meningitisKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment
a. Arrange for humidified oxygen per maskb. Place the child in respiratory isolationc. Inquire about drug allergyd. Hold NPO until orders arrive
30. What should the nurse do when the child arrives on the floor with the diagnosis of bacterial meningitis?
31. ANS: CLong-term exposure to loud noises can damage the fine hair cells in the organ of Corti, which causes a conductive hearing loss.
PTS: 2 DIF: Cognitive Level: Knowledge REF:AHN Page633 Col. 2 Par 2; . Pages 633-635; Review slide 13OBJ: 12 TOP: Health promotion KEY: Nursing Process Step: AssessmentMSC: NCLEX: Health Promotion and Maintenance
a. damaged tympanic membrane.b. protective buildup of cerumen.c. damage of the fine hair cells in the organ of Corti.d. rupture of the oval window.
31. The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to:
a. “Do you have any sensations of pins and needles in your feet?”b. “Does the pain radiate from your back into your legs?”c. “Can you describe the sensations you are having in your head?”d. “Do you ever have any nausea or dizziness?”
32. ANS: CFor patients with suspected neurological conditions, the presence of many symptoms or subjective data may be significant.
PTS: 2 DIF: Cognitive Level: Application REF: Review slide 41;Quiz 1 question 7OBJ: 9 TOP: Assessment KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
32. When obtaining a health history from a patient with a neurological problem, the nurse is likely to elicit the most valid response from the patient with which question?
33. ANS: D“Legal blindness” refers to individuals with a maximum visual acuity of 20/200 with corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories have been established to help determine the exact extent of the vision loss and what assistive measures are appropriate for the individual. The nurse will need more information as to the exact extent of the vision loss for this patient.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 609 | Page 607-610; . Review slide 4OBJ: 6 TOP: Blindness KEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity
a. No vision enhancement techniques would be appropriate for this patient, because he is totally blind.
b. This patient probably has some light perception, but no usable vision.c. This patient has some usable vision, which enables him to function at an acceptable level.d. Further questioning is needed to determine how this patient’s visual impairment affects his
normal functioning.
33. The patient tells the nurse that he is legally blind. This information provides the nurse with which information to use in planning care?
34. ANS: CHospitalization is necessary for GBS patients because the disease progresses very quickly and respiratory failure may occur.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page703; 703-704 Review slide 40OBJ: 18 TOP: Guillain-Barre KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. The infection needs to be treated with IV antibiotics to prevent paralysisb. The brain may swell quickly causing seizuresc. The disease can rapidly progress into respiratory failured. IV hydration is needed to prevent possible fatal hypotension
34. Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately?
35. ANS: CFor patients with suspected neurologic conditions, the presence of many symptoms or subjective data may be significant. Offering leading questions is not beneficial and may allow the patient to give misinformation. Questions should be specific about symptoms.
PTS: 2 DIF: Cognitive Level: Application REF: Review slide 41; Quiz 1 question 7OBJ: 8 TOP: Assessment KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. “Do you have any sensations of pins and needles in your feet?”b. “Does the pain radiate from your back into your legs?”c. “Can you describe the sensations you are having?”d. “Do you ever have any nausea or dizziness?”
35. Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem?
36. ANS: ABefore the dye is injected, patients must be asked whether they have any allergies, specifically whether they have had any anaphylactic or hypotensive episodes from other dyes.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 664; Review slide 33OBJ: 4 TOP: Diagnostic proceduresKEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity
a. Obtain an allergy history before the test.b. Place her in a flat position after the test.c. Warn her that paralysis could result from injection of the contrast medium.d. Keep her NPO for 6-8 hours after the test.
36. A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned for her with respect to this diagnostic test?
37. ANS: AIf the patient with keratoconjunctivitis sicca has associated dry mouth, the patient has Sjögren’s syndrome.
PTS: 2 DIF: Cognitive Level: Application REF:AHN Page 615-616 Review slide 10 OBJ: 4 TOP: Dry eye disorders KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. Keratoconjunctivitis siccab. Conjunctivitisc. Blepharitisd. Opaque lens disorder
37. Sjögren’s syndrome is associated with which eye disorder?
38. ANS: A, B, D, F - sorryThe RAS, located on the brainstem, is essential to wakefulness, attention, concentration, and introspection.
PTS: 2 DIF: Cognitive Level: Analysis REF: Review slide 24OBJ: 1 TOP: reticular activating systemKEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity
a. Concentrationb. Wakefulnessc. Speechd. Attentione. Memoryf. Introspection
38. What is the reticular activating system (RAS) essential to? (Select all that apply.)
39. ANS: ABefore the dye is injected, patients must be asked whether they have any allergies, specifically whether they have had any anaphylactic or hypotensive episodes from other dyes.
PTS: 2 DIF: Cognitive Level: Application REF:AHN Page 664 Review slide 33OBJ: 11 TOP: Diagnostic proceduresKEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity
a. Obtain an allergy history before the test.b. Ambulate the patient when returned to the room after the test.c. Use heated blanket to keep patient warm after procedure.d. Keep NPO for 6 to 8 hours after the test.
39. A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with respect to this diagnostic test?
40. ANS: BAgnosia is a total or partial loss of the ability to recognize familiar objects or people through sensory stimuli as a result of organic brain damage.a. apraxia. – pg 689b. agnosia.- pg 675c. aphasia. – pg 659d. dysphagia. – pg 189
PTS: 2 DIF: Cognitive Level: Comprehension REF: AHN Page 675 Review slide 38OBJ: 16 TOP: Organic brain pathology KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. apraxia.b. agnosia.c. aphasia.d. dysphagia.
40. A patient has been diagnosed with organic brain pathology. He is presenting with signs and symptoms of total or partial loss of the ability to recognize familiar objects or people through sensory stimulation. This condition is called
41. ANS: BMiotics are agents that cause the pupil to contract or constrict.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 625 Review slide 8 OBJ: 9 TOP: Medications KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity
a. mydriatics.b. miotics.c. osmotics.d. inhibitors.
41. A patient is prescribed eyedrops that constrict the pupil, permitting aqueous humor to flow. The nurse would reinforce the teaching by referring to the drops as
42. ANS: DSeizures are followed by a rest period of variable length, called a postictal period.
PTS: 2 DIF: Cognitive Level: Knowledge REF:AHN Page676 Page 676-680 Review slide 39OBJ: 14 TOP: Seizures KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity
a. Convalescent periodb. Neural recovery periodc. Sombulant periodd. Postictal period
42. A family member of a patient who has just suffered a tonic-clonic seizure is concerned about the patient’s deep sleep. What is this behavior called?
43. ANS: BErgotamine tartrate preparations act by constricting the cerebral blood vessel’s walls and reducing cerebral blood flow. These cause reduced inflammation and may reduce pain transmission.
PTS: 2 DIF: Cognitive Level: Comprehension REF: Review slide 30 only Page 665-669 – Rx but does not list this medTOP: Medications KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity
a. dilate cerebral blood vessels.b. constrict cerebral blood vessels.c. reduce neurotransmission of pain impulses.d. enhance endorphin secretion.
43. Ergotamine tartrate medications are beneficial in migraine headaches because they
44. ANS: BBlurring of vision is often the first subjective symptom reported by a patient who has cataracts.
PTS: 2 DIF: Cognitive Level: Application REF:AHN Page 617 Review slide 6OBJ: 9 TOP: Cataracts KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity
a. pain in the eyes.b. blurring of vision.c. loss of peripheral vision.d. dry eyes.
44. A patient has a family history of cataracts. He asks what symptom would be present if he begins to develop them. The nurse might respond that the first symptom of a cataract is usually
45. ANS: ASome forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic disturbance, and malnutrition can all be corrected to abolish the dementia.
PTS: 2 DIF: Cognitive Level: Application REF: You have to choose the least bad answerOBJ: 17 TOP: Causes of dementiaKEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity
a. Hypotensionb. Alzheimer diseasec. Diabetesd. Parkinson disease
45. The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example?
46. ANS: AAutonomic dysreflexia occurs as a result of abnormal cardiovascular response to stimulation of the sympathetic division of the autonomic nervous system as a result of stimulation of the bladder, large intestine, or other visceral organs. The most common cause of this condition includes a distended bladder or fecal impaction.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 710 | Page 710-712 Review slide 35OBJ: 10 TOP: Spinal cord injury KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. bladder distention.b. defecation reflexes.c. postural changes.d. electrolyte imbalance.
46. A patient, age 23, has a comminuted fracture of T6-T7. She has a spinal cord injury resulting in paraplegia. She manifests signs and symptoms of autonomic dysreflexia, which is frequently triggered by
47. ANS: AAstigmatism—blurred vision.
PTS: 2 DIF: Cognitive Level: Knowledge REF:AHN Page 611 | Table 13-3 Page 608-609, 611; Review slide 3OBJ: 4 TOP: Visual acuityKEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. Blurred visionb. Inability to detect colorsc. Color blindnessd. Farsightedness
47. Astigmatism is a medical term meaning which visual disorder?
48. ANS: CIf a patient who has been conscious for several days after head injury loses consciousness or develops neurologic signs and symptoms, a subdural hematoma should be suspected.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page:709 Col1 Para 2 Pages 708-710; Review slide 25OBJ: 19 TOP: Trauma KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. Most injuries of this type are irreversibleb. Open injuries are always more serious than closed injuriesc. Signs and symptoms may not occur until several days after the traumad. Trauma to the frontal lobe is more significant than to any other area
48. What is the nurse aware of when assessing a person with a craniocerebral injury?
49. ANS: BParkinsonism is a syndrome that consists of a slowing down in the initiation and execution of movement (bradykinesia), increased muscle tone (rigidity), tremor, and impaired postural reflexes.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page 685 Pages 683-688; Review slide 38OBJ: 16 TOP: ParkinsonismKEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity
a. multiple sclerosis.b. Parkinsonism.c. Alzheimer’s disease.d. epilepsy.
49. A patient, age 69, is being evaluated by a neurologist for signs of muscle rigidity, masklike face (area from forehead to chin), and propulsive gait. These signs are often characteristic of
50. ANS: AA beta-blocker, such as Betoptic, will reduce intraocular pressure. Miotics such as pilocarpine constrict the pupil and draw the iris away from the cornea, allowing aqueous humor to drain out of the canal of Schlemm.
PTS: 2 DIF: Cognitive Level: Analysis REF:AHN Page;625 Page 623 - 627 | Page 625-626 Medications Table; Review slide 8 OBJ: 7 TOP: Glaucoma KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
a. decrease aqueous humor.b. increase aqueous humor.c. decrease discomfort.d. restore vision.
50. A patient, age 76, is partially blind. His physician has diagnosed open-angle glaucoma. The goal of treatment in glaucoma is to