Complex Med Surg Neuo/GI Exam
Another practice test for my Ivy Tech MS3 Peeps
- 1.
A patient with a history of a-fib would be at highest risk for having a:
- A.
Thrombolytic stroke
- B.
Embolic stroke
- C.
Hemorrhagic stroke
Correct Answer
B. Embolic strokeExplanation
blood clots can form from uncirculated blood in the heart, break off and travel to the brain causing this type of strokeRate this question:
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- 2.
A patient with CAD would be at highest risk of having a:
- A.
Thromboytic stroke
- B.
Embolic stroke
- C.
Hemorrhagic stroke
Correct Answer
A. Thromboytic strokeExplanation
thrombolytic strokes occur due to atherosclerosis of the carotid and vertebral arteries. If a pt already has CAD they probably also have plaques in their other arteries as wellRate this question:
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- 3.
A common TIA usually lasts:
- A.
24 hours to a week
- B.
About 12 hours
- C.
About 1 hour
Correct Answer
C. About 1 hourExplanation
A common TIA usually lasts about 1 hour. This is because a transient ischemic attack (TIA) is a temporary interruption of blood flow to the brain, which can cause stroke-like symptoms. However, the symptoms typically resolve within a short period of time, usually lasting around 1 hour. It is important to seek medical attention immediately if experiencing symptoms of a TIA, as it can be a warning sign of an impending stroke.Rate this question:
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- 4.
A RIND (reversible ischemic neurological defict) usually lasts:
- A.
24 hours to a week
- B.
About 12 hours
- C.
About 1 hour
Correct Answer
A. 24 hours to a weekExplanation
A RIND, or reversible ischemic neurological deficit, refers to a temporary episode of neurological symptoms caused by a temporary disruption of blood flow to a specific part of the brain. The symptoms are similar to a stroke but resolve completely within a relatively short period of time. The correct answer, "24 hours to a week," indicates that a RIND can last anywhere from a day to a week before the symptoms completely disappear. This time frame distinguishes a RIND from a transient ischemic attack (TIA), which typically lasts for less than 24 hours.Rate this question:
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- 5.
A 62 year old man is raking leaves in his lawn when he collapses. The doctors suspect this type of stroke:
- A.
Thrombolytic
- B.
Embolic
- C.
Hemorrhagic
Correct Answer
C. HemorrhagicExplanation
hemorrhagic stroke are associated with adults > 60 yo and with activity while ischemic strokes usually happen at night while pt is resting.Rate this question:
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- 6.
The greatest risk factor for ALL types of stroke is:
- A.
Hypertension
- B.
Atherosclerosis
- C.
DVTs
Correct Answer
A. HypertensionExplanation
Hypertension, also known as high blood pressure, is the greatest risk factor for all types of stroke. Hypertension can lead to the weakening and narrowing of blood vessels, increasing the likelihood of blood clots or ruptures that can cause a stroke. It puts strain on the heart and damages the blood vessels, making them more prone to blockages. Managing and controlling hypertension through lifestyle changes and medication can significantly reduce the risk of stroke. Atherosclerosis, the buildup of plaque in the arteries, and DVTs (deep vein thrombosis) are also risk factors for stroke, but hypertension is the most significant one.Rate this question:
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- 7.
A stroke patient has a hard time seeing and picking up his cup to drink. When he spills, he yells at you and throws his cup. What side of the brain do you think his stroke is affecting?
- A.
Right
- B.
Left
- C.
Both
Correct Answer
A. RightExplanation
right side affects visual/spacial awareness, orientation and causes a pt to be impulsive and have poor judgmentRate this question:
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- 8.
You notice your stroke patient only eats 1/2 of what is on their plate and their left arm is dirty and hanging out of their gown. You suspect they are suffering from _________________ which occurs with a ______________sided stroke
- A.
Bilateral neglect; right
- B.
Unilateral neglect; right
- C.
Unilateral negect; left
Correct Answer
B. Unilateral neglect; rightExplanation
unilateral neglect only occurs with right sided strokes; the pt neglects their left side of the body an can only see 1/2 of the normal visual fieldRate this question:
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- 9.
While having your patient sign an informed consent, you ask the patient if they have any questions and to sign their name. The patient tries to ask a question, gives up and then attempts to sign the consent but cannot do so. You become concerned that the patient might be experiencing a stroke on the ___________side.
- A.
Right
- B.
Left
- C.
Both
Correct Answer
B. LeftExplanation
left sided strokes affect language including speech and writing. Remember the 3 "R's"Rate this question:
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- 10.
The most important diagnostic test for a stroke patient is
- A.
A MRI
- B.
A CT
- C.
A Echocardiogram
Correct Answer
B. A CTExplanation
Remember: door to CT in 30 minutesRate this question:
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- 11.
Which of these interventions can help reduce ICP in a stroke patient?
- A.
Clustering care to give longer rest periods
- B.
Elevating HOB
- C.
Administer stool softeners
- D.
Loosen clothing
- E.
Flexing head back to relieve nuchal rigidity
Correct Answer(s)
B. Elevating HOB
C. Administer stool softeners
D. Loosen clothingExplanation
avoid clustering to decrease stress and give more frequent rest periods; do not flex head or hipsRate this question:
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- 12.
What assessment should be done before administering thrombolytic therapy to a stroke patient?
- A.
PTT and INR levels
- B.
CAT scan
- C.
D-Dimer levels
Correct Answer
B. CAT scanExplanation
The only way to know for sure if the stroke is ischemic or hemorrhagic from the above choices is a CAT scan- do not give thrombolytics to a pt with a hemorrhagic strokeRate this question:
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- 13.
What would be the priority nursing dianosis for a stroke patient?
- A.
Impaired physical mobility
- B.
Impaired verbal communication
- C.
Impaired swallowing
- D.
Incontinence
Correct Answer
C. Impaired swallowingExplanation
Impaired swallowing could lead to aspiration which blocks the airway: ABC'sRate this question:
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- 14.
What is the most frequent symptom of a brain tumor?
- A.
Nausea and Vomiting
- B.
Visual disturbances
- C.
Seizures
- D.
Headache
Correct Answer
D. HeadacheExplanation
Headache is the most frequent symptom of a brain tumor. This is because as the tumor grows, it can put pressure on the surrounding tissues, blood vessels, and nerves in the brain, causing pain and discomfort. Headaches caused by brain tumors are often persistent and worsen over time. Other symptoms such as nausea and vomiting, visual disturbances, and seizures can also occur, but headache is the most common and often the first symptom experienced by patients with a brain tumor.Rate this question:
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- 15.
Your patient is post-op from a craniotomy. You notice his urine output is 40mL/hr and his serum sodium is 155. You suspect he might be suffering from:
- A.
Meningitis infection secondary to craniotomy
- B.
SIADH- Syndrome of inappropriate anti-diuretic hormone
- C.
Diabetis Insipidus
- D.
Hydrocephalus due to ICP
Correct Answer
C. Diabetis InsipidusExplanation
increased ICP puts pressure on the pituitary gland which can cause it to increase or decrease production of ADH. In this case, increased UO and increased sodium are symptomatic of DI. If UO decreased and Na was low, it would be SIADHRate this question:
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- 16.
The most common cause of Spinal Cord Injuries is
- A.
Falls
- B.
MVA's (Motor Vehicle Accidents)
- C.
Acts of Violence
- D.
Sports
Correct Answer
B. MVA's (Motor Vehicle Accidents)Explanation
Motor Vehicle Accidents (MVA's) are the most common cause of Spinal Cord Injuries. This is because during car accidents, the force and impact can cause severe trauma to the spinal cord, leading to injuries. The sudden jolt or impact can result in fractures or dislocations of the vertebrae, which can damage the spinal cord. The high speed and force involved in MVA's make them a major cause of spinal cord injuries. Falls, acts of violence, and sports-related injuries can also cause spinal cord injuries, but MVA's are the most common cause.Rate this question:
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- 17.
Your patient was rear-ended waiting for the light to turn green. She comes in to the ER complaining of neck pain and numbness. You suspect her injury was caused by this mechanism:
- A.
Hyperflexion
- B.
Hyperextension
- C.
Vertebral compression
- D.
Rotation
Correct Answer
B. HyperextensionExplanation
head-on is hyperflexion and rear-ended is hyperextension. I remember the difference by thinking I would extend my neck to turn around and look behind me.Rate this question:
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- 18.
What medication would you expect your MVA patient to be put on upon admission to the hospital?
- A.
Mannitol
- B.
Decadron
- C.
Dilantin
- D.
Methylprednisolone
Correct Answer
D. MethylprednisoloneExplanation
SCI patients are put on methylprednisolone IV for the first 24 hour after trauma to reduce swelling around the spinal cordRate this question:
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- 19.
You check up on you SCI patient; her vitals are: T- 97.2, P-56, R-12, BP- 90/47. You suspect she might be suffering from:
- A.
Autonomic dysreflexia
- B.
Neurogenic Shock
- C.
Cushing's Reflex
- D.
Hemorrhagic Shock
Correct Answer
B. Neurogenic ShockExplanation
Although rare, these are s/s of neurogenic shock: The spinal cord is in initial shock from trauma causing injury to the sympathetic pathways in the SC. S/S- bradycardia, hypothermia and hypovolemia leading to hypotensionRate this question:
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- 20.
You have a parapalegic patient admitted for the treatment of a decubitus ulcer. His 0800 vitals are: T- 98.8, P- 82, BP- 134/60, R-18. You do a second set of vitals at 1200 which are: T-98.6, P- 65, BP- 165/82, R- 18. He also complains of a punding headache.Your first intervention should be:
- A.
Nothing- all vital signs are WNL
- B.
Administer tylenol as written on prn orders for HA and continue to monitor
- C.
Raise the HOB to decrease ICP and headache pain
- D.
Check foley catheter for kinks or obstructions
Correct Answer
D. Check foley catheter for kinks or obstructionsExplanation
even though these vitals are WNL, the increase in BP with the decrease in Pulse and onset of HA could signify Autonomic Dysreflexia. The primary cause of this in SCI patients is overfilled bladder so the foley should be checked first.Rate this question:
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- 21.
Your neighbor's child falls from his skateboard and hits his head on the sidewalk. He is dazed but in a couple of minutes says he is fine. His mom calls you that evening during dinner worried because keeps laying his head on the table,won't eat and just asks to be put to bed. You advise her to take him to the hospital because:
- A.
You think he might have a subdural hemotoma
- B.
You think he migh thave a epidural hematoma
- C.
You think he might have a concussion
- D.
You don't want to get sued because he fell on the sidewalk in front of your house
Correct Answer
B. You think he migh thave a epidural hematomaExplanation
epidual bleeds are more common with falls/trauma; their is usually a brief LOC followed by lucidity and then s/s withing 2 hours of injury. An subdural bleed usually takes days to weeks to see any s/s. Subdurals are more common with MVA'sRate this question:
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- 22.
Your TBI patient is being monitored for ICP. His latest reading was 10 mmHg. You assess:
- A.
This is WNL and no intervention is needed
- B.
This is mildly elevated ICP- make sure the HOB is up and the lights are low
- C.
This is a moderate increase in ICP- administer mannitol as rx
- D.
This is a significant increase in ICP- use the catheter to draw off 10mL of IC fluid
Correct Answer
A. This is WNL and no intervention is neededExplanation
Normal ICP is 0-10 mmHgRate this question:
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- 23.
What is the first intervention for increased ICP?
- A.
Sedation
- B.
Mannitol
- C.
Hyperventilation
- D.
Phenobarbitol
Correct Answer
A. SedationExplanation
sedation is first- the rest go in the order of interventionsRate this question:
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- 24.
I have reviewed the Pain and Coma Worksheets and feel confident that I could answer any question posed from them.
- A.
True
- B.
False
Correct Answer
A. TrueExplanation
The given statement suggests that the person has thoroughly examined the Pain and Coma Worksheets and is now fully prepared to respond to any question related to them. Therefore, the correct answer is true, indicating that the person is confident in their knowledge and understanding of the Pain and Coma Worksheets.Rate this question:
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- 25.
Most of the complications that arise from Hepatitis occurs from:
- A.
Hepatic cell death
- B.
Hepatic cell injury
- C.
Hepatic cell hypoxia
- D.
Hepatic cell carcinoma
Correct Answer
B. Hepatic cell injuryExplanation
In hepatitis, inflammation leadsto injury of cells but not cell deathRate this question:
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- 26.
A group of highschool kids come down with flu-like symptoms after eating out after a football game saturday night. The culprit is probably:
- A.
Hepatitis A
- B.
Hepatitis B
- C.
Hepatitis C
Correct Answer
A. Hepatitis AExplanation
Hepatitis A is spread via oral-fecal route and is common in preschools and restraunts where employees do not wash their hands.Rate this question:
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- 27.
Which of the following medication regimens are safe for preventing chemical induced hepatitis?
- A.
Extra-strength tylenol (500mg) 2 tabs q 6 hrs
- B.
Darvocet (625mg acetaminophen) 2 tabs q 6 hours
- C.
Norco (325 mg acetaminophen) 2 tabs q 4-6 hours
- D.
Tylenol #3 (325 mg acetaminophen) 2 tabs q 4 hours
Correct Answer(s)
A. Extra-strength tylenol (500mg) 2 tabs q 6 hrs
C. Norco (325 mg acetaminophen) 2 tabs q 4-6 hours
D. Tylenol #3 (325 mg acetaminophen) 2 tabs q 4 hoursExplanation
The Darvocet is the only regimen that exceeds 4000mg of acetaminophen in a 24 hour periodRate this question:
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- 28.
Which of the following are indicated for a pt receiving a Liver Biopsy procedure?
- A.
NPO
- B.
Informed Consent
- C.
Heparin therapy
- D.
Coagulation studies
Correct Answer(s)
B. Informed Consent
D. Coagulation studiesExplanation
NPO is not necessary d/t no conscious sedation; heparin therapy is contra-indicated because high risk of bleeding due to vascularity of liver.Rate this question:
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- 29.
What is the primary nursing intervention for the patient with hepatitis?
- A.
Fluid restrictions
- B.
Rest
- C.
Antiemetics
- D.
High calorie diet
Correct Answer
B. RestExplanation
all are important but rest is the primary intervention b/c it decreases the liver's metabolic demands and increases the liver's blood supply allowing regeneration of cellsRate this question:
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- 30.
You get lab results from your patient who has been admitted with an undiagnosed illness. Which lab results would indcate liver cirrhosis as a possibility?
- A.
Increased AST and LDH
- B.
Increased protein and albumin levels
- C.
Decreased bilirubin levels
- D.
Increased ammonia
- E.
Increased PTT
Correct Answer(s)
A. Increased AST and LDH
D. Increased ammonia
E. Increased PTTExplanation
for cirrhosis,all lab levels increase EXCEPT protein and albuminRate this question:
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- 31.
The TIPS procedure is used to treat:
- A.
Esophageal varices
- B.
Portal hypertension
- C.
Ascites
- D.
Coagulation defects
Correct Answer
B. Portal hypertensionExplanation
The TIPS procedure, or Transjugular Intrahepatic Portosystemic Shunt, is a minimally invasive procedure used to treat portal hypertension. Portal hypertension is a condition where there is increased blood pressure in the portal vein, which carries blood from the digestive organs to the liver. This can lead to complications such as esophageal varices, which are enlarged veins in the esophagus, and ascites, which is the accumulation of fluid in the abdomen. The TIPS procedure involves creating a shunt between the portal vein and the hepatic vein to relieve the pressure and improve blood flow. It is not used to treat coagulation defects.Rate this question:
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- 32.
Your patient has a Sengstaken- Blakemore tube inserted to treat esophagal varicies secondary to liver cirhosis. You notice the marking of the tube previously at his nose is now down at his chin level. You:
- A.
Push the tube back in until the mark is at nose-level and re-tape it
- B.
Re-inflate the bladder to the gastric balloon to anchor it back in the stomach
- C.
Cut the ends of the tubes and remove quickly to prevent asphyxiation
- D.
Continue to observe the tube marking- some variations are normal
Correct Answer
C. Cut the ends of the tubes and remove quickly to prevent asphyxiationExplanation
remember: scissors at the bedside in case of this type of emergency!Rate this question:
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- 33.
Your patient with cirrhosis and ascites begins having bleeding from his gums and eyes. What is the diagnosis?
- A.
DIC (disseminated Intravascular coagulation)
- B.
HIT (heparin induced toxicity)
- C.
CIA (cirrhosis induced anemia)
- D.
IDK (I don't know)
Correct Answer
A. DIC (disseminated Intravascular coagulation)Explanation
when fluid leaks into the paritoneal cavity in ascites it takes clotting factors with it from the blood. This reduction in clotting factors causes DIC whose s/s are bleeding from injection sites, the skin or cavities of the bodyRate this question:
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- 34.
Which of the following are appropriate inteventions for Portal-systemic encephalopathy?
- A.
Low protein diet
- B.
Lactulose
- C.
Neomycin
- D.
Levodopa
Correct Answer(s)
A. Low protein diet
B. Lactulose
C. Neomycin
D. LevodopaExplanation
all are correctRate this question:
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- 35.
The primary cause of death related to cirrhosis is due to:
- A.
Heart-failure r/t fluid retention from ascites
- B.
Hypovolemia r/t espageal varicies
- C.
Hepato-renal syndrome r/t kidney failure
- D.
Stroke d/t portal hypertension
Correct Answer
C. Hepato-renal syndrome r/t kidney failureExplanation
The primary cause of death related to cirrhosis is hepato-renal syndrome, which is kidney failure caused by liver dysfunction. In cirrhosis, the liver becomes severely damaged and is unable to perform its normal functions, leading to a buildup of toxins in the body. These toxins can damage the kidneys and impair their ability to filter waste products from the blood. As a result, kidney failure can occur, leading to a cascade of complications that can ultimately be fatal.Rate this question:
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- 36.
A patient with liver cancer undergoes a lobectomy to remove a tumor. Along with bleeding, what other assessments are important for the nurse to perform?
- A.
Serum blood levels of AST and blirubin every 8 hours for 48 hours post surgery
- B.
Accuchecks q 6 hours to determine blood glucose levels
- C.
Percussion of surgical area to assess for fluid retention
- D.
Assess reflexes q shift
Correct Answer
B. Accuchecks q 6 hours to determine blood glucose levelsExplanation
the liver produces sugars through glucogenesis; when part of it is removed it produces less glucose causing hypoglycemiaRate this question:
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- 37.
A patient undergoes surgery for esophagea cancer. The disease part of the esophagus is removed and replaced b a section of the:
Correct Answer
jejunumExplanation
The patient undergoes surgery for esophageal cancer, where the diseased part of the esophagus is removed. To replace this section, a portion of the jejunum is used. The jejunum is a part of the small intestine that is located between the duodenum and the ileum. This surgical procedure is known as esophageal reconstruction or esophageal replacement. By using a section of the jejunum, the surgeon can create a new pathway for food and liquids to pass through, allowing the patient to continue eating and drinking normally after the surgery.Rate this question:
- 38.
The diagnostic tool of choice for a diagnosis of gastric cancer is
- A.
A MRI
- B.
Endoscopy
- C.
EGD (esophagealgogastoduodenoscopy)
- D.
CAT scan
Correct Answer
C. EGD (esophagealgogastoduodenoscopy)Explanation
The diagnostic tool of choice for a diagnosis of gastric cancer is EGD (esophagealgogastoduodenoscopy). This procedure allows the doctor to visually examine the lining of the esophagus, stomach, and upper small intestine using a flexible tube with a camera on the end. It can also be used to take tissue samples for further testing. MRI and CAT scans can provide detailed images of the stomach, but they are not as effective in detecting small abnormalities or taking tissue samples. Endoscopy offers a direct and accurate visualization of the stomach, making it the preferred choice for diagnosing gastric cancer.Rate this question:
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- 39.
Blood in the stool could be indicative of this type of cancer:
- A.
Gastric
- B.
Esophageal
- C.
Duodenal
- D.
Colorectal
Correct Answer
D. ColorectalExplanation
Blood in the stool is a common symptom of colorectal cancer. Colorectal cancer refers to cancer that starts in the colon or rectum. The presence of blood in the stool can be caused by the growth of tumors in the colon or rectum, which can bleed and result in blood being visible in the stool. This symptom should not be ignored and should prompt further medical investigation to determine the cause and appropriate treatment.Rate this question:
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- 40.
Most patients diagnosed with Pancreatic Cancer catch the disease early with a 60-70% chance of remission
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
Most pancreatic cancer is detected only after it has advanced and cannot be resected. Prognosis is poor.Rate this question:
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- 41.
Your patient is havin 10+ liquid stools per day with abdominal cramping and pain. Her diagnosis is most likely
- A.
Ulcerative Colitis
- B.
Chron's Disease
- C.
Pacreatitis
- D.
IBS
Correct Answer
A. Ulcerative ColitisExplanation
UC affects the whole colon from the rectum to the cecum preventing fluid absorption from the stool causing it to be liquifiedRate this question:
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- 42.
Chron's disease is characterized by 5-6 soft, loose stools daily. This is because the inflammation is commonly located in the:
- A.
Transverse colon
- B.
Teminal ilium
- C.
Descending colon
- D.
Ascending colon
Correct Answer
B. Teminal iliumExplanation
inflammation in the ilium occur prior to the colon so stools still have water extracted from them preventing liquid consitencyRate this question:
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- 43.
One medication that might be indicated for a patient with chronic pancreatitis that would not be needed for a patient with acute pancratitis would be:
- A.
Opiods
- B.
Phenergan
- C.
Insulin
- D.
Reglan
Correct Answer
C. InsulinExplanation
chronic pancratitis damages the liver to the extent where it cannot make insulin any longer causing DM and insulin dependencyRate this question:
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- 44.
Diverticulitis is diagnosed as being found in the:
- A.
Ascending colon
- B.
Transverse colong
- C.
Desending colon
- D.
Sigmoid colon
Correct Answer
D. Sigmoid colonExplanation
Diverticulitis is a condition characterized by inflammation or infection of small pouches called diverticula that form in the walls of the colon. These diverticula are most commonly found in the sigmoid colon, which is the S-shaped portion of the large intestine located just before the rectum. The sigmoid colon is a common site for diverticula formation due to increased pressure and muscle contractions in this area. Therefore, diverticulitis is typically diagnosed when these pouches become inflamed or infected in the sigmoid colon.Rate this question:
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- 45.
Your patient has an ostomy placed at her ascending colon. You would expect her stool to have the following consistency:
- A.
Solid
- B.
Semi-solid
- C.
Mushy
- D.
Liquid
Correct Answer
D. LiquidExplanation
The ascendin colon is the beginning of the colon right after the terminal ilium- stool is still liquid at this point.Rate this question:
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- 46.
You are providing teaching to your patient going home with an ostomy bag. You tell them they should change the bag when:
- A.
It is completely full
- B.
It is half full
- C.
It is 1/4 full
Correct Answer
C. It is 1/4 fullExplanation
Smeltzer reccomends 1/4-1/3 full to prevent the weight of the effluent from pulling the bad down and breaking the sealRate this question:
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- 47.
When would you advise your ostomy patient irrigate their ostomy?
- A.
3 times a day- once after each meal
- B.
Once a day in the morning
- C.
Once a day in the evening
- D.
Once a day after a meal
Correct Answer
D. Once a day after a mealExplanation
Irrigating an ostomy involves flushing the stoma with water to remove waste and promote regular bowel movements. It is generally recommended to irrigate once a day after a meal. This timing helps to ensure that the bowel is relatively empty and the irrigation process is more effective. Irrigating after a meal also allows for better control of bowel movements throughout the day, reducing the risk of accidents or discomfort.Rate this question:
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- 48.
What is the major assessment a nurse needs to consider when administering TPN?
- A.
Hypervolemia
- B.
Blood Sugar
- C.
Blood Pressure
- D.
Allergic Reaction
Correct Answer
B. Blood SugarExplanation
TPN is high in glucose so blood sugar levels need to be watched as the pancrease adjusts insulin coverage during the period of TPN administrationRate this question:
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- 49.
You can administer IV medications through a TPN line
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
TPN (Total Parenteral Nutrition) is a specialized form of nutrition support that provides all nutrients intravenously. It is given through a dedicated line called a TPN line, which is specifically designed for TPN administration. TPN lines are not meant for administering medications, as they are solely used for delivering nutrition. Therefore, it is not appropriate to administer IV medications through a TPN line.Rate this question:
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- 50.
A classmate finishes taking this test on tuesday and comments the she was so nervous her heart is racing. You take her pulse and it is 130 BPM. You advise her to:
- A.
Go to Peppers and a have beer instead of attending lecture before having to sit through the 2 hour CAAP exam
- B.
Put her head between her knees
- C.
Bear down like she is having a bowel movement
- D.
Calm down- we are all stressed out and she just needs to deal with it!
Correct Answer
C. Bear down like she is having a bowel movementExplanation
tachycardi can sometimes be stopped by performing the vagal manuver- bearing down or coughingRate this question:
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