Ncm 104 ncm 104

Total Flash Cards » 145
Text Size » S M L     
 
1. 
. The physician prescribed Ergotamine tartrate (Gynergen) for a client with migraine headaches. The client asks the nurse why she has migraine headaches. What is the nurse’s best response?
 
Migraine headaches are believed to be caused by the dilation of the cranial arteries.
 
2. 

. Kelly Smith complains that her headaches are occurring more frequently despite medications. Patients with a history of headaches should be taught to avoid?

 
Chocolate
 
3. 
The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
 

Call the physician immediately.

 
4. 

The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor?

 
Prinzmetal’s angina
 
5. 

The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?

 
Take the patient’s vital signs.
 
6. 

The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take?

 
The nurse should clear the area and position the client safely
 
7. 
The client is experiencing seizure due to chemical imbalances. The following are causes of seizure because of chemical imbalances EXCEPT:
 
Alkalosis
 
8. 
The nurse is preparing a diet plan for a patient experiencing seizures. What plan of diet should the nurse prepare?
 
a diet high in fat and very low in carbohydrates and protein which can produced Ketosis
 
9. 

In giving health teachngs to a patient experiencing seizures,the diet plan that should be avoided includes:

 

Avoid excess sugar and caffeine

 
10. 
A patient is suddenly having seizure. As a nurse, an initial nursing intervention should include:
 
Place the patient on side during a seizure
 
11. 

Assessment of Generalized tonic-clonic (grand mal) seizure includes all of the following EXCEPT:

 
Loss of contact with environment for 5 to 30 seconds.
 
12. 
The following are complications related to seizure EXCEPT:
 
Hypertension
 
13. 

A patient is admitted to the hospital for epeliptic seizure. Medications include which of the following:

 
Anticonvulsants
 
14. 

A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting physician writes orders for actions to be taken in the event of a seizure. Which of the following actions would NOT be included?

 
Restrain the patient's limbs
 
15. 

1. Which of the following best describes hydrocephalous?

 

Abnormal accumulation of CSF in the ventricles

 
16. 

1. Which is not a symptom of acquired hydrocephalous?

 

Delirium

 
17. 

1. All of the following are causes of acquired hydrocephalous except?

 

Infection

 
18. 

1. What procedure that involves the placement of a ventricular into the cerebral ventricles to drain the excess fluid into the other body cavities?

 

VP shunt

 
19. 

1. Intra-axial tumors originate from the glial cells and arise from within the following except?

 

Meninges

 
20. 

1. It is common in patients with intracranial tumors and may be the first manifestation. It is also known as “Choked Disc”?

 

Papilledema

 
21. 

1. Patient Magangana was diagnosed with brain tumor. She was scheduled for craniotomy. In preventing development of cerebral edema after surgery, the nurse should expect the use of what medication?

 

Steroids

 
22. 

1. All but one is the best nursing responsibility of Nurse Magangana to take action regarding monitoring for an increase ICP

 

Assess neurologic status and vital signs frequently

 
23. 

1. Patient MD had a head trauma. She experience loss of consciousness for 5 minutes and retrograde amnesia. There was no break in her skull or dura and no visible damage as seen in MRI. Nurse GGV knows that this type of trauma is________

 

Concussions

 
24. 

1. ___________ is the most severe form of head injury because there is no focal lesion to remove.

 

Diffuse Axonal injury

 
25. 

1. The medical management of severely head-injured patients focuses on supporting all organ system while recovery from the injury takes place. This involves ___________

 

All of the above

 
26. 

1. A patient has loss of consciousness lasting 6 to 24 hours and has a short-term disability. What type of diffuse axonal injury does the patient manifest?

 

Mild axonal injury

 
27. 

1. Clinical manifestations of arteriovenous malformation include all the following except:

 

Focal neurologic lesions

 
28. 

1. A patient is admitted with essential arteriovenous malformation. The nurse knows that most AVM are caused by an abnormality in embryonal development that leads to:

 
Tangle arteries and veins in the brain that lacks in capillary bed.
 
29. 
The nurse advises Mr. Nathan to bed rest with sedation. This advice is based on the knowledge that rest and sedation
 

Prevent agitation and stress

 
30. 

1. Doppler Ultrasonography of cerebrovascular system is used for arteriovenous malformation that indicates:

 

Turbulent blood flow

 
31. 

1. All of the following are cause by cerebral aneurysm except:

 

Alcoholism

 
32. 
This is the most common type of cerebral aneurysm
 

Saccular or berry aneurysm

 
33. 
Cerebral aneurysm most commonly occur at the bifurcations of the large arteries at the base of the brain, what is the specific location?
 

Cerebral arterial circle

 
34. 

1. A female client with a suspected brain tumor is cheduled for computed tomography (CT). what should the nurse do when preparing the client for this test?

 

Determine whether the client is allergic to iodine, contrast dyes, or shellfish

 
35. 

1. The nurse is caring for a child with spina bifida which of the following factors determines the extent of sensory and motor function loss in the lower limbs of the child?

 

Degree of spinal cord abnormality

 
36. 

1. Which assessment findings suggest hydrocephalus?

 

Rapid increase in head size and irritability

 
37. 

1. Which technique is more important for diagnosing hydrocephalus?

 
Measurement of head circumference
 
38. 
All of the following are common etiology of spina bifida
 

None of the above

 
39. 

1. Where is the usual location of meningocele?

 

Posterior vertebral arches

 
40. 

1. Which one of the following phrases most accurately describes myelomeningocele?

 

Herniation of a portion of the spinal cord and meninges into a cyst.

 
41. 

1. A female patient is diagnosed with a CVA in the left hemisphere. The nurse explains to the patient that her cerebral accidents (stroke) occurred in the left hemisphere of her brain; therefore, she will have paresis (weakness) on

 

The right side of the body.

 
42. 

1. A male patient recovering from a CVA is receiving oxygen therapy. The action the nurse should take before starting oxygen therapy is to?

 
Keep the patient’s head slightly elevated and clear his mouth of secretions
 
43. 

1. The most common motor dysfunction of a stroke is:

 
Hemiplegia
 
44. 

1. The degree of neurologic damage that occurs with the ischemic stroke depends on the:

 

Combination of the above factors.

 
45. 

1. A patient suffered a spinal cord injury in a swimming accident that resulted in quadriplegia. The nurse recognizes that the one major early problem for a quadriplegia will be:

 

Learning to use mechanical aids

 
46. 

1. The rehabilitation nurse is admitting a client following spinal cord injury. The nurse concludes that the client has developed Brown-Sequared syndrome after noting which of the following in the client?

 

Ipsilateral proprioception loss below lesion

 
47. 

1. A client who is recovering from a spinal cord injury complains of blurred vision and a severe headache. His blood pressure is 210/140. The most appropriate initial action for the nurse to take is:

 

Check for bladder distention

 
48. 

1. When the nurse asks a male patient with parkinson’s disease to undress, the nurse observes that the patient’s upper arm tremors disappear as he unbuttons his shirt. Which of the following statement would be the best to guide the nurse when analyzing her observation?

 

This type of tremor usually disappears with purposeful and voluntary movements.

 
49. 

1. A client with Parkinson’s disease is receiving combination therapy with Levodopa (L-dopa) and Carbidopa (Sinemet). Which of the following manifestations indicate to the nurse that an adverse drug reaction is occurring?

 

Depression

 
50. 

1. A nurse is teaching a family of a client with Parkinson’s disease. Which of the following statements by the family reflects a need for more education?

 

“We can buy lots of soups for dad.”

 
51. 

1. The nurse is admitting a male patient with Parkinson’s disease to the hospital records that the patient has a shuffling and propulsive gait. If the nurse is using the term propulsive gait correctly, she has observed that the patient’s walk is characterized by:

 
slumping forward while walking
 
52. 

1. Signs and symptoms seen in Parkinson’s Disease result from the fact that the patient’s body suffer from a:

 

depletion of dopamine

 
53. 

1. Which of the following nursing goals is most realistic and appropriate in caring for a patient with Parkinson’s disease?

 

Cure the disease in three to five years

 
54. 

1. When the nurse asks a male patient with Parkinson’s disease to undress, the nurse observes that the patient’s upper arm tremors disappear as he unbuttons his shirt. Which of the following statements would be best to guide the nurse when analyzing his observation?

 

This type of tremors usually disappears with purposeful and voluntary movements

 
55. 

1. This type of food should be avoided when taking Levodopa except:

 

a. Apple

 
56. 

1. This is a diagnostic procedure in patients with spinal cord injury if a ligamentous injury is suspected.

 

a. MRI

 
57. 
These are possible cause of hemorrhagic stroke, except
 
Venous Thrombosis
 
58. 

1. A nurse is caring for a patient diagnosed with hemorrhagic stroke; the nurse would be alert for this complication.

 

Seizure

 
59. 

1. IN relation to ischemic stroke, penumbra region is referred to:

 

An area of low cerebral blood flow

 
60. 
. ____________ an autoimmune disorder caused by the destruction of acetylcholine receptors.
 
Myasthenia Gravis
 
61. 
Myasthenic crisis and cholinergic crisis are the major complications of myasthenia gravis. Which of the following is essential nursing knowledge when caring for a client in crisis?
 

a. Weakness and paralysis of the muscles for swallowing and breathing occur in either crisis

 
62. 

3. A client is admitted to the medical-surgical floor with an exacerbation of myasthenia gravis. Which intervention is important for the nurse to include in the plan of care for this client?

 
. Scheduling the client's care around periods of rest.
 
63. 
Karina, a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:
 
Decreases the production of auto antibodies that attack the acetylcholine receptors
 
64. 

The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?

 

Progressive weakness that is worse at the day’s end

 
65. 

1. All of the fallowing are clinical manifestation of Guillain Barre Syndrome except:

 

Headache

 
66. 

1. It is not recommended for the treatment of GBS

 
Corticosteroids
 
67. 

1. In respiratory distress with Guillain Barre Syndrome, we monitor for the fallowing except

 
Vital signs
 
68. 

1. The cell that produces myelin in the nerve

 
Schwann cell
 
69. 

1. Cerebral Palsy can be diagnosed as early as _____________?

 
4 months
 
70. 

1. Result in the damage or defects in the brains corticospinal pathways in either one or both hemispheres?

 
a) Pyradimal/ spastic
 
71. 

1. 1. common The type of cerebral palsy

 

a) Spastic cerebral palsy

 
72. 

1. In planning a diet for a client with cerebral palsy, what would be the most appropriate

 
High calorie diet
 
73. 

. Which of the following pathophysiologic processes are involved in Multiple Sclerosis ?

 

Developmental of demyelination of the myelin sheath, interfering with nerve transmission

 
74. 
Which of the following symptom usually occurs early in multiple sclerosis?
 
Diplopia
 
75. 
The client with multiple sclerosis is experiencing dysphagia. Which of the following foods is the most important for the client?
 
vanilla pudding
 
76. 

Which of following condition or activities may exacerbate multiple sclerosis (MS)?

 
pregnancy
 
77. 

Which of the following client would be most likely to develop multiple sclerosis (MS)?

 
A 35 years old white female teacher
 
78. 

1. The patient is suffering from herniated nucleus pulposus. Which of the following does not aggravate the pain?

 

a. Bed rest

 
79. 

1. The patient is experiencing muscle spasm. All of the following but one is not an appropriate intervention?

 

a. Narcotics

 
80. 

1. A pre-op patient who underwent a laminectomy needs further instruction if she states that;

 

a. I’m not allowed to drink for four days

 
81. 

1. A patient was admitted to the hospital. The physician diagnosed the condition of the patient as herniated nucleus pulposus. The nurse on duty knows that herniated nucleus pulposus is the;

 

a. Profusion of the central part of interverfebral disk with the spinal canal casing compression of spinal nerve roots.


 
82. 

1. As a nurse, you know that herniated nucleus pulposus is dominant to men due to the heavy lifting. It is common in the _______and less common/rare in _______ vertebral _______.

 

a. Lumbar; cervical; space

 
83. 

1. A patient came into the emergency complaining of an increasing throbbing headache that she characterized as a persistent aching and burning pain. The nurse knows that the patient is suffering from a temporal arteritis. All of these are associated factors of temporal arteritis except?

 
Nausea and vomiting
 
84. 

1. Tension headache is the most common type of headache, as a nurse you know that tension headaches can be treated with all of the following except?

 

a. Corticosteriods

 
85. 

1. A patient complains of experiencing deep-seated, throbbing pain and describes the pain as aching or bursting. The nurse knows that the patient is suffering from headaches of brain tumor that causes attacks of pain lasting a few minutes to an hour or more. All the following are associated factors except one;

 

a. Loss of vision

 
86. 

1. Mr X was diagnosed with seizure. The affected part of his brain is the frontal lobe. Nurse A would expect the pt. to have:

 

a. Tremors that begin in the hands with unimpaired LOC

 
87. 

1. Mrs Samantha has a history of seizure while gardening. The patient suddenly losses consciousness and fell on the floor. Upon assessment, the patient has minimal abrasions increase pulse rate and perspiring. As a nurse, you know that the patient has a;

 

a. Grand mal Seizure

 
88. 

1. The physician ordered an anticonvulsant drug for a patient with seizure one of the nursing consideration is;

 

a. An anticonvulsant should not be given with narcotic analgesics

 
89. 

1. Nurse Anna is monitoring the vital signs of the patient with seizures/ What are the important vital signs should nurse Anna take?

 

a. CV status, temperature and Respiration

 
90. 

1. Andie has bacterial meningitis, which of the following drug is most likely to administer for early diagnosis.

 

a. Vancomycin HCI with cephalosporins

 
91. 

1. People in class contact with meningococcal meningitis should be treated with antimicrobial prophylaxis. The medication should be administered:

 

a. Within 24 hrs.

 
92. 

1. A patient who diagnose of meningitis can manifest a frequently initial symtoms that the patient will experience throughout the course of illness. Which of the ff. experiencing?

 

d. Headache and fever

 
93. 

1. Doctor Jonathan diagnosed Mr. Santiago to have intracranial hemorrhage between cranium and outside the dura.The doctor is correct if he interprets that Epidural Hemorrhage is frequently due to:

 

c.Rupture of middle meningeal artery

 
94. 

17.Nurse Sarra is aware that Nuerological signs of Intracranial Hemorrhage includes:EXCEPT

 

b.Increase in respiratory

 
95. 

18. This results from spontaneous rupture of a small penetrating artery deep in the brain?

 

d. Intracerebral Hemorrhage

 
96. 

19. Mr. Reyes experienced pain when he flexed and extend his thigh on his abdomen at right angle. This situation is significantly positive to what condition?

 

d. Kernig’s Sign

 
97. 

20. Antifibrolytics are used in the management of haemorrhagic lesion to:

 

b. prevent fibrin clot degeneration

 
98. 

1. After experiencing a transient ischemic attack, a client is prescribed aspirin, 325 mg p.o. daily. The nurse should teach the client that this medication has been prescribed to:

 

d. Reduce platelet agglutination

 
99. 

2. A 70 year old client with a diagnosis of left sided CVA is admitted to the facility. To prevent the development of disuse osteoporosis, which of the following objectives is most appropriate?

 

c. Promoting weight bearing exercises

 
100. 

3. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?

 

b. Ineffective airway clearance

 
101. 

4. A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. the nurse should plan to:

 

a. Increase the frequency of the catheterizations

 
102. 

5. A client undergoes cerebral angiography for nurse evaluation of neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure which findings indicate spasm or occlusion of a cerebral vessel by a clot?

 

b. Hemiplegia, seizures, and decreased level of consciousness

 
103. 

6. The nurse formulates a nursing diagnosis of risk for altered body temperature for a client who suffers a CVA after surgery. When developing expected outcomes, the nurse incorporate assessment of the client’s temperature to detect abnormalities. The thermoregulatory centers are located in which part of the brain?

 

d. Hypothalamus

 
104. 

7. A client recovering from a CVA has right sided hemiplegia and telegraphic speech and often seems frustrated and agitated especially when trying to communicate. However the chart indicates that the client‘s auditory and reading comprehension are intact. The nurse suspects that the clients has:

 

b. Non-fluent aphasia

 
105. 

8. A client with parkinson’s disease visits the physician’s office for a routine check-up. The nurse notes that the client takes benztropine(cogentin), 0.5 mg p.o. daily and asks when the client takes the drug during each day. Which response medicates that the client understands when to take benztropine?

 

d. “I take the medication at bedtime”

 
106. 

9. After a CVA, a 75 yr old client is admitted to the facility. The client has left sided weakness and an absent gag reflex. He’s incontinent and has a tarry stool. His blood pressure is 90/50 mmHg, and his Hgb is 10g. Which of the following is a priority for this client?

 

d. Elevating the head of the bed to 30 degrees

 
107. 

10. During recovery from CVA, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet , the nurse assesses the clients swallowing ability once each shift. This assessment evaluates:

 

d. CN IX & X

 
108. 

11. The nurse is caring for a client with hemiparesis caused by a CVA. Which intervention takes the highest priority?

 

b. Placing the client on the affected side

 
109. 

12. A client injures the spinal cord in a diving accident. The nurse knows that the client will be unable to breathe spontaneously if the injury site is above which vertebral level?

 

a. C4

 
110. 

13. A white female client is admitted to an acute care facility with a diagnosis of CVA. Her history reveals bronchial asthma, exogenous obesity and iron deficiency anemia. Which history findigs is a risk factor for CVA?

 

c. Obesity

 
111. 

14. When teaching a client about levodopa carbidopa (sinemet) therapy for Parkinson’s disease, the nurse should include which instruction?

 

d. “be aware that your urine may appear darker than usual”

 
112. 

15. The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

 

a. Heparin sodium (heparin sodium injection)

 
113. 

16. A client who recently experienced a CVA tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

 

b. Alternatively patch one eye every 2 hours

 
114. 

17. For a client who has had a CVA, which nursing intervention can help prevent contractures in the lower legs?

 

d. Attaching braces or splints to each foot and leg

 
115. 

18. If a client experienced a cerebrovascular accident that damaged the hypothalamus, the nurse would anticipate that the client has problems with:

 

a. Body temperature control

 
116. 

19. Vince William, age 65 years old, is admitted to the hospital with a diagnosis of Parkinson’s disease. Joel’s symptoms are caused by:

 

d. an imbalance in dopamine and acetylcholine

 
117. 

20. Which clinical feature of the disease should the nurse expect to see during admission assessment?

 

b. mask like face and shuffling gait

 
118. 

1. The physician told that baby Megamind needs to undergo surgery that will create an opening to allow CSF to drain through a shunt from ventricles of the brain into cisterna magna. What is this surgical procedure?

 

a. Ventriculocisternostomy

 
119. 

1. It is a diagnostic procedure wherein a light is shone through a body area or organ.

 

a. Transillumination

 
120. 

1. Patient megamind was diagnosed with non communicating or intraventricular hydrocephalus, as a nurse we know that this problem can cause a non- communicating hydrocephalus.

 

a. Arnold-Chiari Syndrome

 
121. 

1. Clarissia an 8y/o child that has been diagnosed to have brain tumor. The doctor advised the parents of clarissa to get their child for treatment. You know as a nurse that the best treatment for clarissa would be:

 

a. Chemotherapy

 
122. 

6. In relation to the question in no.1. Clarissa’s parents ask what is the action of the treatment. As a nurse your answer would be:

 

a. It’s goal is to kill tumor cells with the aid of drugs.

 
123. 

7. Leren has breast cancer for 5 years, the cancer has already metastasized through her body reaching the brain . What do you call this condition?

 

b. Secondary brain tumor

 
124. 

10. Patient Tin is classified as grade 3 in Spetzler Martin Grading for microsurgery. What does it implies?

 
a. She may or may not be amenable for a surgery
 
125. 

11. This is a type of stroke that is caused by bleeding into the subarachnoid space in the area between the brain and the skull which contain CSF.

 

b. SAH

 
126. 

12. Mr. Q was diagnosed with AVM. What part of the brain is removed if he is required to have a supra tentorial surgery?

 

c. Above the tentorium

 
127. 

13. Mr. R, a 42 years old police officer was diagnosed of having AVM and was ready to undergo what appropriate type of surgery?

 

b. microsurgery

 
128. 

14. Baby Marco, a 7 months old is brought by his mother to the hospital because of noticeable enlargement of the head. As a student nurse you know that baby Marco is suffering from hydrocephalus because as you further assess the symptom it shows the ff. except:

 

d. Nuchal rigidity

 
129. 

15. In relation to question #6 after the diagnostic procedure is done, baby Marco have to undergo surgery. Prior to surgery you do your nursing management that include the ff. except:

 

d. Monitor for Signs and Symptoms or HCP and infection

 
130. 

16. Mr. You was brought to the Emergency Department by his wife due to the vehicular accident. The patient undergone an immediate Skull x-ray that reveals Mr. You has Depressed Skull Fracture. As a nurse, you are aware the characteristic of Depressed Skull Fracture is?

 

a. A break in a cranial bone or "crushed" portion of skull with depression of the bone in toward the brain

 
131. 

17. Nurse Biwit is taking the history of his patient experiencing head injury, he should know that the most common symptom of concussion is

 

a. Headache

 
132. 

18. Nurse Biwit has a patient who has a historyof head injury, during health teaching, nurse Biwit includes all of the following regarding the prevention of head injury except?

 

*c. Cap in construction

 
133. 

19. A 55 y/o male client was diagnosed with fusiform cerebral aneurysm that needs an urgent medical treatment . What should be the first nursing intervention?

 

* b. Monitor V/S

 
134. 

20. A relative of a client with cerebral aneurysm ask the nurse what does it means. The nurse’s appropriate response would be:

 

*c. “Is a dilation of the walls of the cerebral artery that develops as a result of weakness in the arterial wall”.

 
135. 

1. You are about to administer 20 mg. of Capoxane to a patient with relapsing-remitting Multiple Sclerosis, what is the only route used in administering this drug?

 

a. Subcutaneous

 
136. 

1. Which of the following suggest why patients with Multiple Sclerosis develop depression?

 

a. Depression is a side effect of some drugs used to treat MS such as steroids and Interferon.

 
137. 

1. What is the virus most often associated with Guillaine-Barre Syndrome?

 

a. Campylobacter Jejuni

 
138. 

1. Because Myasthenia Gravis may involve the muscle of respiration, what action will you do to prevent a patient from experiencing dyspnea and ineffective cough and swallow mechanism?

 

a. Encourage deep breathing and coughing.

 
139. 

1. This is an autoimmune disease that persists on muscular weakness and fatigue that worsens with exercise and improves with rest?

 

a. Myasthenia Gravis

 
140. 

1. Brad Feet a 25 year old patient with Guillaine-Barre Syndrome is having a respiratory distress which of the following will you expect to see connected to the patient?

 

a. Mechanical Ventilator

 
141. 

1. Which of the following diagnoses is appropriate for a client with Multiple Sclerosis?

 

a. Impaired urinary elimination related to bladder dysfunction.

 
142. 

1. Which of the following is a unique clinical manifestation of Guillaine-Barre Syndrome?

 

a. Ascending weakness

 
143. 

1. Type of extra pyramidal cerebral palsy manifested by wormlike abnormal involuntary movement?

 

a. Athethoid

 
144. 

1. What is the drug administered to patients with Multiple Sclerosis that prohibits the inflammatory cascade to prevent damage to the myelin?

 

a. Copaxone

 
145. 

1. What neurotransmitter receptor is decreased in patients with Myasthenia Gravis?

 

a. Acetylcholine Receptor