Nursing Exam Questions on Spinal Cord Injury, Myasthenia Gravis, and Delirium, Exams of Nursing

Download Nursing Exam Questions on Spinal Cord Injury, Myasthenia Gravis, and Delirium and more Exams Nursing in PDF only on Docsity! NURS 423 Exam 4 When caring for a patient who has admitted was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? 1. Continuous cardiac monitoring for bradycardia 2. Administration of methylprednisolone infusion 3. Assessment of respiratory rate and depth 4. Application of pneumatic compression devices to both legs - answer; 3. Assessment of respiratory rate and depth The nurses caring for a patient who sustained a spinal cord injury during administration of morning care the patient begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1. elevate the head of the bed 2. check the pmts urinary catheter for kinking 3. assess the pmts blood pressure 4. place the pt in the prone position - answer; 1. elevate the head of the bed A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of the following findings, its utmost concern to the nurse? 1. SpO2 of 92% 2. HR of 42bpm 3. BP of 112/70 4. Loss of motor and sensory function in the arms and legs - answer; 2. HR of 42bpm In assessing a patient with a teeth 12 spinal cord injury which clinical manifestations with the nurse expect to find to support the diagnosis of spinal shock? 1. Inability to move upper extremities 2. No reflex activity below the waist 3. Complaints of a pounding headache 4. Hypotension and bradycardia - answer; 2. No reflex activity below the waist A patient is being evaluated to rule out Myasthenia Gravis, and it's being administered the tensilon test. Which response to the test indicates the patient has Myasthenia gravis? 1. The pt has no apparent change in the assessment data 2. There is increased amplitude of electrical stimulation in the muscles 3. The circulating acetylcholine receptor antibodies are decreased 4. The pt shows a marked improvement of muscle strength - answer; 4. The pt shows a marked improvement of muscle strength The nurses caring for a patient who has been recently diagnosed with Myasthenia Gravis. The nurse should teach the patient that Myasthenia Gravis is caused by? 1. Amyloid plaques and neurofibrillary tangles 2. Destruction of acetylcholine receptors 3. Degeneration of dopamine-producing neurons in the basal ganglia 4. Demyelination of nerve fibers in the brain and spinal cord - answer; 2. Destruction of acetylcholine receptors When planning care for the patient with trigeminal neuralgia which patient outcome should the nurse set as the highest priority? 1. Maintenance of positive body image 2. Protection of the cornea 3. Relief of pain 4. Maintenance of nutrition - answer; 3. Relief of pain The nurse is performing an assessment on a patient with the diagnosis of Bell's palsy. The nurse should expect to observe which finding in the patient? 1. Periorbital edema 2. Facial drooping 3. Prosis of the eyelid 4. Twitching on the affected side of the face - answer; 2. Facial drooping the ED nurse receives report that a patient involved in a motor vehicle crash is being transported to the facility with an estimates arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain: 1. Hypothermia 2. LR 3. Two 14-gauge IV catheters 4. Dopamine infusion - answer; 3. Two 14-gauge IV catheters Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? 1. Hemoglobin is within normal limits 2. Urine output is 60mL over the last hour 3. Central venous pressure is normal 4. Mean arterial pressure is 72mmHg - answer; 2. Urine output is 60mL over the last hour A patient with septic shock has a BP of 70/46 mmHg, pulse 136, respirations 32, Temp is 104F and BG 46. Which intervention ordered by the health care provider should the nurse implement first? 1. Give NS IV at 500mL/hr 2. Give acetaminophen (Tylenol) 650mg rectally 3. Start insulin drip to maintain BG at 110 to 150mg/dL 4. Start norepinephrine to keep systolic BP >90mmHg - answer; 1. Give NS IV at 500mL/hr The nurse advises a patient with myasthenia gravis (MG) to: a. perform physically demanding activities early in the day. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d.protect the extremities from injury due to poor sensory perception. - answer; a. perform physically demanding activities early in the day. A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion (ROM). b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures. - answer; a. Assist with active range of motion (ROM). Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness - answer; c. Respiratory effort Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patients bowel sounds. b. Notify the patients health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone). - answer; b. Notify the patients health care provider. * cholinergic crisis=atropine After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as like a band around my head c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinsons disease who has developed cogwheel rigidity of the arms - answer; a. Patient with myasthenia gravis who is reporting increased muscle weakness *myasthenic crisis A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patients speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years. - answer; a. The patient was oriented and alert when admitted. Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration. - answer; b. Remind the patient frequently about being in the hospital. When administering a mental status examination to a patient with delirium, the nurse should: a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination. - answer; c. choose a place without distracting stimuli. The nurse is concerned about a postoperative patients risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation. - answer; d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation. The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? a. Keep blinds open during the daytime hours. b. Provide hourly orientation to time and place. c. Have the patient take a brief mid-morning nap. d. Move the patient to a quieter room late in the afternoon. - answer; a. Keep blinds open during the daytime hours. The nurses initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to a. reorient the patient to time, place, and person. b. administer a PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. assign unlicensed assistive personnel (UAP) to stay in the patients room. - answer; c. assess for factors that might be causing discomfort. When administering the Mini-Cog exam to a patient with possible Alzheimers disease, which action will the nurse take? a. Check the patients orientation to time and date. b. Obtain a list of the patients prescribed medications. c. Ask the person to use a clock drawing to indicate a specific time. d. Determine the patients ability to recognize a common object such as a pen. - answer; c. Ask the person to use a clock drawing to indicate a specific time. Which hospitalized patient will the nurse assign to the room closest to the nurses station? a. Patient with Alzheimers disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination - answer; c. Patient with new-onset confusion, restlessness, and irritability after surgery After change-of-shift report on the Alzheimers disease/dementia unit, which patient will the nurse assess first? a. Patient who has not had a bowel movement for 5 days b. Patient who has a stage II pressure ulcer on the coccyx c. Patient who is refusing to take the prescribed medications d. Patient who developed a new cough after eating breakfast - answer; d. Patient who developed a new cough after eating breakfast *aspiration After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimers disease, which topic will be most important for the nurse to discuss with the patient? a. Tobacco use b. Family history c. Head injury history d. Total cholesterol level - answer; a. Tobacco use *modifiable risk factor The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about a. visual problems caused by ptosis. b. triggers leading to facial discomfort. c. poor appetite caused by loss of taste. d. weakness on the affected side of the face. - answer; b. triggers leading to facial discomfort. Which action should the nurse take when assessing a patient with trigeminal neuralgia? a. Have the patient clench the jaws. b. Inspect the oral mucosa and teeth. c. Palpate the face to compare skin temperature bilaterally. d. Identify trigger zones by lightly touching the affected side. - answer; b. Inspect the oral mucosa and teeth. When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia, the nurse will a. assess whether the patient is doing daily facial exercises. b. question whether the patient is using an eye shield at night. c. ask the patient about social activities with family and friends. d. remind the patient to chew on the unaffected side of the mouth. - answer; c. ask the patient about social activities with family and friends. Which action will the nurse include in the plan of care for a 62-year-old patient who is experiencing pain from trigeminal neuralgia? a. Assess fluid and dietary intake. b. Apply ice packs for 20 minutes. c. Teach facial relaxation techniques. d. Spend time talking with the patient. - answer; a. Assess fluid and dietary intake. The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bells palsy. Which information should the nurse include in teaching the patient? a. You may be able to prevent Bells palsy by doing facial exercises regularly. b. Prophylactic treatment of herpes with antiviral agents prevents Bells palsy. c. Medications to treat Bells palsy work only if started before paralysis onset. d. Call the doctor if you experience pain or develop herpes lesions near the ear. - answer; d. Call the doctor if you experience pain or develop herpes lesions near the ear. A 32-year-old pregnant patient with Bells palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse is to a. respect the patients feelings and arrange for privacy at mealtimes. b. teach the patient to chew food on the unaffected side of the mouth. c. offer the patient liquid nutritional supplements at frequent intervals. When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to a. drive a car with powered hand controls. b. push a manual wheelchair on a flat surface. c. turn and reposition independently when in bed. d. transfer independently to and from a wheelchair. - answer; b. push a manual wheelchair on a flat surface. A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells the nurse I want to be transferred to a hospital where the nurses know what they are doing! Which action by the nurse is best? a. Clarify that abusive language will not be tolerated. b. Request that the patient provide input for the plan of care. c. Perform care without responding to the patients comments. d. Reassure the patient about the competence of the nursing staff. - answer; b. Request that the patient provide input for the plan of care. A 38-year-old patient has returned home following rehabilitation for a spinal cord injury. The home care nurse notes that the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The most appropriate action by the nurse at this time is to a. remind the patient about the importance of independence in daily activities. b. tell the spouse to stop because the patient is able to perform activities independently. c. develop a plan to increase the patients independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patients care and encourage that participation. - answer; c. develop a plan to increase the patients independence in consultation with the patient and the spouse. A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by health care provider will the nurse question? a. Encourage oral fluids to 3 L/day b. Document neurologic symptoms c. Position patient lying on the side d. Observe respiratory status closely - answer; a. Encourage oral fluids to 3 L/day Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Application of pneumatic compression devices to legs d. Administration of methylprednisolone (Solu-Medrol) infusion - answer; b. Assessment of respiratory rate and effort A 27-year-old patient is hospitalized with new onset of Guillain-Barr syndrome. The most essential assessment for the nurse to carry out is a. determining level of consciousness. b. checking strength of the extremities. c. observing respiratory rate and effort. d. monitoring the cardiac rate and rhythm. - answer; c. observing respiratory rate and effort. Before administering botulinum antitoxin to a patient in the emergency department, it is most important for the nurse to a. obtain the patients temperature. b. administer an intradermal test dose. c. document the neurologic symptoms. d. ask the patient about an allergy to eggs. - answer; b. administer an intradermal test dose. A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to a. administer humidified oxygen by mask. b. suction the patients mouth and nasopharynx. c. push upward on the epigastric area as the patient coughs. d. encourage incentive spirometry every 2 hours during the day. - answer; c. push upward on the epigastric area as the patient coughs. A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, I have a pounding headache and I feel sick to my stomach. Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed analgesic. c. Assess the blood pressure (BP). d. Notify the health care provider. - answer; c. Assess the blood pressure (BP). A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? a. The patient has new onset weakness of both legs. b. The patient complains of chronic severe back pain. c. The patient starts to cry and says, I feel hopeless. d. The patient expresses anxiety about having surgery. - answer; a. The patient has new onset weakness of both legs. Which of these nursing actions for a 64-year-old patient with Guillain-Barr syndrome is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)? a. Nasogastric tube feeding q4hr b. Artificial tear administration q2hr c. Assessment for bladder distention q2hr d. Passive range of motion to extremities q4hr - answer; d. Passive range of motion to extremities q4hr Which action will the nurse take when caring for a 46-year-old patient who develops tetanus from an injectable substance use? a. Avoid use of sedatives. b. Provide a quiet environment. c. Check pupil reaction to light every 4 hours. d. Provide range-of-motion exercises several times daily. - answer; b. Provide a quiet environment. c. Epinephrine (Adrenalin) drip d. Hydrocortisone (Solu-Cortef) - answer; b. Furosemide (Lasix) IV *reduces preload Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching. - answer; b. Monitor breath sounds frequently. 11. Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patients central venous pressure is 3 mm Hg. b. The patient is in sinus tachycardia at 120 beats/min. c. The patient is receiving low dose dopamine (Intropin). d. The patient has had no urine output since being admitted. - answer; a. The patients central venous pressure is 3 mm Hg. *normal is 2-6 A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat cardiogenic shock. Which finding indicates that the medication is effective? a. No new heart murmurs b. Decreased troponin level c. Warm, pink, and dry skin d. Blood pressure 92/40 mm Hg - answer; c. Warm, pink, and dry skin Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation - answer; d. Oxygen saturation Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patients serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patients extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields. - answer; a. The patients serum creatinine level is elevated. *renal/heart failure When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock - answer; d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock *poikilothermia The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Blood pressure (BP) 92/56 mm Hg b. Skin cool and clammy c. Oxygen saturation 92% d. Heart rate 118 beats/minute - answer; b. Skin cool and clammy A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. obtain a 12-lead electrocardiogram (ECG). c. obtain the blood pressure. d. check the level of consciousness. - answer; a. administer oxygen. *ABCs During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Heart rate 112 beats/minute c. Decreased bowel sounds d. Pale, cool, and dry extremities - answer; a. New onset of confusion *progressive stage of shock A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Initiate continuous electrocardiogram (ECG) monitoring. c. Provide oxygen at 100% per non-rebreather mask. d. Draw blood to type and crossmatch for transfusions. - answer; c. Provide oxygen at 100% per non- rebreather mask. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patients heart rate is 58 beats/minute. b. The patients extremities are warm and dry. c. The patients IV infusion site is cool and pale. d. The patients urine output is 28 mL over the last hour. - answer; c. The patients IV infusion site is cool and pale.