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Nurs 6202 Exam 3 Prep (Module Assessments + Review Q's) With Complete Solutions A client with an onset of Bell's palsy is very upset and crying about the change in facial appearance. The nurse plans to emotionally support the client by telling the client that: a. This is similar to a stroke, but all symptoms will reverse without treatment b. This is not a stroke and many clients recover in 3-5 weeks This caused by a small tumor, which can be easily c. removed d. This is a temporary problem, with treatment similar to that for migraine headaches Correct Answers b. This is not a stroke and many clients recover in 3-5 weeks
- Clts w/ Bell's palsy should be reassured that they have not experience a stroke & that sx often disappear spontaneously 3- weeks.
- This clt is given supportive tx for sx
- Not usually caused by a tumor, & the tx is not similar to that for migraine HA A client with myasthenia gravis has nursing diagnosis of "Risk for Ineffective Airway Clearance and Risk for Ineffective Breathing Pattern. The nurse would keep which of the following available at the client's bedside? a. Incentive spirometer and cough pillow b. Oxygen and metered dose inhaler c. Pulse oximeter and a cardiac monitor d. Ambu bag and suction equipment Correct Answers d. Ambu bag and suction equipment
- Clt w/ MG may experience episodes of respiratory distress if excessively fatigued, or if the clt develops myasthenic crisis or cholinergic crisis. For this reason, an ambu bag, intubation tray & suction equipment should be available at the bedside A complete spinal cord injury can often be from: a. Unstable ligament support b. bone fragments are causing mechanical pressure c. no vasomotor control d. An incomplete SCI Correct Answers d. An incomplete SCI A nurse has given instructions to a client with Parkinson's disease about maintaining mobility. The would evaluate that the client understood the directions if the client states he or she should: a. Exercise in the evening to combat fatigue b. Rock back and forth to start movement with bradykinesia c. Sit in soft, deep chairs d. Buy clothes with many buttons to maintain finger dexterity Correct Answers b. Rock back and forth to start movement with bradykinesia
- Clt w/ Parkinson's disease should exercise in the morning when energy lvls are highest.
- Clt should avoid sitting in soft, deep, chairs, bc they are difficult to get up from
- Clt can rock back & forth to initiate movement.
- Clt should buy clothes w/ Velcro fasteners & slide-locking buckles to support the ability to dress
c. What would you like to do instead? d. The treatment is only temporary. Correct Answers c. What would you like to do instead? A patient with seizures is to receive a medication dose of 125 mg through his PEG tube three times a day. The patient's med drawer contains oral syringes with 125 mg/5 mL. How many milliliters should be given with the next administration? Answer must include unit of measure. a. 5 mL b. 2 mL c. 4.25mL d. 4 mL Correct Answers a. 5 mL A patient with spinal shock example is: a. HR 42 BP 190/124, RR 36, T 94. b. HR 42, BP 88/42, RR 16, T 94. c. HR 148, BP 88/40, RR 14, T 103 d. HR 42, BP, 90/40, RR 14, T 103.6 Correct Answers b. HR 42, BP 88/42, RR 16, T 94. A priority assessment for a patient with myasthenia gravis is: a. Checking blood pressure b. hand strength c. consciousness level d. respiratory rate Correct Answers d. respiratory rate absence seizure Correct Answers Brief loss of consciousness, seen mostly in children.
According to protocol, what do you do for a patient in Autonomic Dysreflexia? Match the order of priority. Correct Answers 1. sit them upright
- check the bladder
- contact the provider
- loosen tight clothing
- administer ordered BP med
- document the occurence treatment, and response
- teach patient and family/caregiver S&S and treatment of AD ALS Correct Answers Progressive neurodegenerative disease that affects cells in the brain and spinal cord. ALS nursing interventions are targeted at: a. Facilitating communication b. Reducing aspiration c. Diarrhea d. Decreasing pain d/t muscle weakness Correct Answers a. Facilitating communication b. Reducing aspiration d. Decreasing pain d/t muscle weakness ALS patho includes: a. Rare b. Women are affected more than med c. Progressive d. Characterized by the loss of motor neurons Correct Answers a. Rare c. Progressive d. Characterized by the loss of motor neurons
b. Teach the patient and family c. Assess d. apply a bandage Correct Answers d. apply a bandage autonomic dysreflexia Correct Answers Medical emergency, sympathetic mediated vasoconstriction. Occurs in patients with lesions above T6. Autonomic dysreflexia treatment is: a. document, treat, elevate HOB, call MD b. Document, raise HOB, check bladder, call MD c. elevate HOB, check bladder, Call MD, document d. check bladder, call MD, elevate HOB, document Correct Answers c. elevate HOB, check bladder, Call MD, document Autonomic hyperreflexia symptoms are: SATA a. HA b. anxiety c. flushing d. blurred vision Correct Answers a. HA b. anxiety c. flushing d. blurred vision Brown-Sequard syndrome Correct Answers Ipsilateral motor response and contralateral sensory loss Brown-Sequard Syndrome is characterized by: a. one leg- no motor function, other leg-loss of pain and temp b. loss of awareness of leg position but has motor control c. Only one leg is affected
d. Loss of control in both legs Correct Answers a. one leg- no motor function, other leg-loss of pain and temp cluster headache Correct Answers One sided head pain, often around the eyes. Tearing of the eyes may occur. Describe autonomic hyperreflexia & dysreflexia. What are some ssx? Correct Answers Autonomic dysreflexia/hyperreflexia is a massive uncompensated CV reaction mediated by the SNS below the level of the SCI. SSx: Massive sympathetic outflow - HTN, bradycardia Above lesion level - profuse swearing, HA, Flushed face & upper chest, nasal congestion, piloerection Below lesion level - dry & pale skin Describe Guillain-Barré syndrome Correct Answers Ascending symmetric paralysis Most serious complication - respiratory dilantin Correct Answers Seizure medication which can only be diluted with normal saline. Distal cord and nerve root injury can be called: a. Brown-Sequard syndrome b. Anterior cord injury c. Cauda Equina/Conus Medullaris d. posterior cord injury Correct Answers c. Cauda Equina/Conus Medullaris
- In the postictal phase of generalized tonic-clonic seizures, patients are usually very tired and may sleep for several hours and the nurse should allow the patient to sleep as long as needed. Gout pain is: a. slow and progressive b. severe and sudden c. severe but subsides quickly d. slow over a 5 days period Correct Answers b. severe and sudden Gout treatment includes: SATA a. corticosteroid b. palpate area of pain for assessment c. elevate foot d. remove anything from touching painful joint Correct Answers a. corticosteroid d. remove anything from touching painful joint Guillain-Barre patho includes: a. Occurs after a bacterial or viral infection b. Entire loss of mylin with edema and inflammation c. Acute, ascending, rapidly progressing, symmetric weakness of the limbs d. Autoimmune process Correct Answers a. Occurs after a bacterial or viral infection c. Acute, ascending, rapidly progressing, symmetric weakness of the limbs d. Autoimmune process
Guillain-Barre syndrome is caused from: a. Your patient tells you he was recently bitten by a bee b. Your patient tells you he was sick 2 weeks ago c. Your patient tells you his father had it d. Your patient tells you he has a history of severe allergies Correct Answers b. Your patient tells you he was sick 2 weeks ago Guillain-Barre syndrome therapies include: a. Supportive care b. Dilantin c. IVIG d. Plasmapheresis Correct Answers a. Supportive care c. IVIG d. Plasmapheresis Guillian-Barre Syndrome (GBS) include: a. hypotonia b. areflexia c. respiratory failure d. paresthesias Correct Answers a. hypotonia b. areflexia c. respiratory failure d. paresthesias most important is to think about ABC's HA's occur repeatedly and at the same time of the day or night affecting men more than women? a. Rebound b. Cluster
In 24 hours, a patient consumed 2 cups of soup and 3 cups of coffee. The UAP empties 500 mL from the foley bag. Which is greater, intake or output? By how much? Answer must include unit of measure. a. Intake by 700 mL b. Intake by 680 mL c. Output by 50 mL d. Intake by 720 mL Correct Answers a. Intake by 700 mL Memorize that 1 cup or 8 oz = 240 mL In a C7 spinal cord injury the pt is: a. at risk for increasing blood sugars b. Has full function of legs c. Unable to detect pain but can feel temperature d. at risk for a DVT Correct Answers d. at risk for a DVT In observing a client with a suspected diagnosis of Parkinson's Disease the nurse would expect the following clinical manifestations a. Flaccidity, bradykinesia, visual disturbances b. Patchy blindness, ptosis, tremors c. Tremor, rigidity, bradykinesia d. Ataxia, restless legs, cogwheeling Correct Answers c. Tremor, rigidity, bradykinesia Low back pain is often: a. can be cured b. treatable without surgery c. Often progresses as you age
d. becomes worse with activity Correct Answers b. treatable without surgery lower motor neuron Correct Answers Characterized by decreased muscle tone, and atrophy. multiple sclerosis Correct Answers Possibly a viral disease in which symptoms worsen with stress. Symptoms vary and may include fatigue, visual changes, weakness, numbness and spasticity. My sister has been relapsing remitting MS. what kind of sc would you expect? Correct Answers Remember nerves sheats are damage so some have ataxia, vision issues, (optic neuritis), weakness & numbness & tingling.
- look up other types of MS myasthenia gravis Correct Answers Chronic autoimmune neuromuscular disease which causes weakness in the voluntary muscles of the body Myasthenia gravis patho includes: a. Autoimmune process that attacks acetylcholine receptors b. Men are affected more than women c. The course of disease is universal d. Increases with muscle use Correct Answers a. Autoimmune process that attacks acetylcholine receptors d. Increases with muscle use
d. Can urinate on their own Correct Answers b. Breath on their own c. Can lift arms proprioception Correct Answers Refers to position sense; body location in space. Remember SCI will vary depending on the level on injury. Make sure you understand sx at e/a level. What is someone was poikilothermic? Correct Answers You would make sure the room temp was adequate. What if a pt has a cervical SCI? The most important assessment you will be assessing is BREATHING. Shuffled, forward tilted, stooped gait is a characteristic of w/c neurologic disorder? a. Parkinson's disease b. Multiple sclerosis (MS) c. Myasthenia gravis d. ALS Correct Answers a. Parkinson's disease Spasticity is expected d/t: a. an upper motor neuron injury b. A lumbar injury c. A thoracic injury d. lack of physical therapy Correct Answers a. an upper motor neuron injury Spinal shock is: a. Loss of proprioception b. diminished or loss of reflexes
c. Sudden loss of motor control d. Loss of temperature control after 48 hours Correct Answers b. diminished or loss of reflexes Swelling and bleeding of the gums can be an adverse reaction to: a. Gentamycin b. Corticosteroids c. Phenytoin d. Levadopa-Carbidopa Correct Answers c. Phenytoin Sx of MS include: SATA a. weakness b. the loss of full control of bodily movements. c. Numbness and tingling d. Vision problems Correct Answers a. weakness b. the loss of full control of bodily movements. c. Numbness and tingling d. Vision problems The best statement for your patient who tells you (RN) about her RA symptoms is: a. We can treat your symptoms b. The biologic medications can reverse RA c. There is no cure d. Marijuana helps Correct Answers a. We can treat your symptoms The most important technique for diagnosing headaches is______________ a. Cerebral blood flow studies
d. Increased erythrocyte sedimentation rate (ESR) Correct Answers c. Increased joint pain and stiffness after periods of activity Joint pain precipitated by activity & relieved by rest. Pain may be d/t articular distension, stretching of the joint fibers, may involve single or multiple joints. Crepitus & grinding evident when joint moved, joint may feel hard to touch ESR increase-marker of inflammation, increase seen w/ RA, CRP is also elevated in RA The nurse cares for the client with a 15 yr-history of SLE. The client's BP is 158/94 and pretibial edema is present. The client's serum potassium levels are increased and the serum hemoglobin level is low. Which process best describes the reason for these findings? a. Degranulation of mast cells and release of histamine and serotonin. b. Formation of antigen-antibody complexes that lodge in small blood vessels. c. Release of massive amounts of IgE and leukotrienes d. Lysis of the antibody molecules and release of sensitized T cells. Correct Answers b. Formation of antigen-antibody complexes that lodge in small blood vessels. Antigen-antibody (immune complexes) are formed during Type III hypersensitivity rxn; SLE is autoimmune disorders; antibodies formed against collagen & cellular DNA; immune complexes deposit in small blood vessels; vasculitis &
inflammatory response in blood vessels cause tissue damage, kidney, brain & myocardial vessels frequently affected. A - degranulation of mast cells occur during Type I hypersensitivity rxns C - release of IgE & leuotrienes associated w/ Type I hypersensitivity response D - antibodies attach to antigens & form immune complexes, no lysis occurs The nurse determines that teaching about the management of osteoarthritis of the feet and hands has been effective when the patient says, a. "I will be careful to avoid crowds and people with infections." b. "I can use heat to relieve the stiffness when I wake up in the morning." c. "I should exercise my hands every day, especially if they are painful and inflamed." d. "I should avoid the use of glucosamine as it has been shown to have no therapeutic value." Correct Answers b. "I can use heat to relieve the stiffness when I wake up in the morning." Effective management of osteoarthritis includes the following: heat therapy stiffness, including hot packs, whirlpool baths, ultrasound, and paraffin wax baths during any periods of acute inflammation & maintained in a functional position w/ splints or braces if necessary; cortisone injections have a local effect, & the pt will not develop immunosuppression; nutritional supplements such as glucosamine & chondroitin sulfate may be helpful in some patients for relieving moderate to severe arthritis pain in the knees & improving joint mobility.
