Med-surg Tb Neuro 22-24

74 Questions | Total Attempts: 138

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Med-surg Tb Neuro 22-24 - Quiz

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Questions and Answers
  • 1. 
    The nurse is caring for the patient who has had an injury to the hypothalamus. Which intervention will the nurse be most concerned with implementing?
    • A. 

      Maintaining environmental temperature control

    • B. 

      Monitoring for signs of hemorrhage

    • C. 

      Protecting the eyes from bright lights

    • D. 

      Providing care designed to preserve skin integrity

  • 2. 
    The nurse differentiates the sympathetic from the parasympathetic nervous systems in that the sympathetic system:
    • A. 

      Provides energy for “fight or flight” in stressful situations.

    • B. 

      Slows the heart rate after a stressful situation.

    • C. 

      Supports deep sleep after large expenditures of energy.

    • D. 

      Relaxes blood vessels to counteract hypertension.

  • 3. 
    The nurse assessing an 80-year-old attributes the slowed knee jerk reflex with which age-related change?
    • A. 

      Diminished brain cells

    • B. 

      Degeneration of myelin sheath

    • C. 

      Weakened muscles

    • D. 

      Irritation of nerve roots

  • 4. 
    A student nurse questions the nurse about the difference between a quadriplegic and a tetraplegic patient. The nurse correctly reports that a tetraplegic patient:
    • A. 

      Has fewer fine motor movements.

    • B. 

      Can experience pain in paralyzed parts.

    • C. 

      Is more easily rehabilitated.

    • D. 

      Means the same as a quadriplegic.

  • 5. 
    The nurse requesting the patient to stick out the tongue and move it rapidly from side to side is assessing the __________ nerve.
    • A. 

      Hypoglossal

    • B. 

      Glossopharyngeal

    • C. 

      Vagal

    • D. 

      Abducens

  • 6. 
    The nurse may record a positive Romberg’s test if during the test, the patient:
    • A. 

      Cannot keep his eyes closed.

    • B. 

      Cannot touch his nose with eyes closed.

    • C. 

      Complains of dizziness.

    • D. 

      Sways from side to side.

  • 7. 
    The nurse explains that a reflex is a simple automatic response requiring only:
    • A. 

      One efferent and one afferent impulse and a synapse.

    • B. 

      Two efferent impulse and one synapse.

    • C. 

      Two synapses with efferent and afferent impulses.

    • D. 

      Two afferent impulses and one synapse.

  • 8. 
    The nurse interprets the physician’s finding of a grade of 2/5 on the Achilles tendon to mean what has occurred?
    • A. 

      Hyperreflexive response for the fifth and sixth cervical nerves

    • B. 

      Exaggerated response for the seventh and eighth cervical nerves

    • C. 

      Normal response for the first and second sacral nerves

    • D. 

      Weak response for the second through the fourth lumbar nerves

  • 9. 
    The reflex that indicates an abnormality in the motor control pathways from the cerebral cortex is the __________ reflex.
    • A. 

      Babinski

    • B. 

      Biceps

    • C. 

      Brachioradialis

    • D. 

      Knee jerk

  • 10. 
    The vital sign assessment of a person with a head injury was temperature (T), 97° F; pulse (P), 86; respiration (R), 18; and blood pressure (BP), 140/86 at 1:00. Which vital sign assessment made 30 minutes later is indicative of increasing intracranial pressure (ICP)?
    • A. 

      T, 98° F; P, 78; R, 14; BP, 150/82

    • B. 

      T, 97° F; P, 90; R, 20; BP, 148/94

    • C. 

      T, 98° F; P, 82; R, 18; BP, 140/74

    • D. 

      T, 99° F; P, 92; R, 16; BP, 136/82

  • 11. 
    The nurse notes that the Glasgow Coma Scale rating made on the patient 4 hours ago indicated a fully alert patient with a score of _____ points.
    • A. 

      25

    • B. 

      20

    • C. 

      15

    • D. 

      10

  • 12. 
    The assessment of a patient’s ability to think can be evaluated by asking the patient:
    • A. 

      To add three numbers together in his head.

    • B. 

      To identify the name of the present month.

    • C. 

      What he would do in the event of a fire.

    • D. 

      What the last major holiday was.

  • 13. 
    The nurse is performing a neurologic assessment on a newly admitted head injury patient. Which sign does the nurse recognize as that most indicative of a brainstem injury?
    • A. 

      Nystagmus

    • B. 

      Decerebrate posturing

    • C. 

      Seizure activity

    • D. 

      Glasgow Coma Scale score of 3

  • 14. 
    The crossed arms of the examiner when assessing muscle strength in a neurologic assessment is done in order to:
    • A. 

      Align the examiner’s hands with the patient’s hands.

    • B. 

      Create greater distance between the examiner and the patient.

    • C. 

      Allow a comfortable stance for the examiner.

    • D. 

      Equalize sensitivity of the examiner’s hands.

  • 15. 
    When feeding a patient with dysphagia with a left-sided hemiplegia, how should the nurse position the patient?
    • A. 

      Side-lying on the right side

    • B. 

      Semi-Fowler’s

    • C. 

      High Fowler’s

    • D. 

      Upright at a table in a wheelchair

  • 16. 
    Bladder training begins with toileting the patient every:
    • A. 

      Hour

    • B. 

      2 hours

    • C. 

      3 hours

    • D. 

      4 hours

  • 17. 
    A patient is admitted to the hospital to rule out the possibility of bacterial meningitis. Which test will be most helpful in diagnosing this condition?
    • A. 

      Magnetoencephalography (MEG)

    • B. 

      Myelography

    • C. 

      Cerebral angiography

    • D. 

      Lumbar puncture for cerebrospinal fluid (CSF) analysis and culture

  • 18. 
    The patient scheduled for a PET (positron emission tomography) scan of the brain asks if there is any special preparation for the test. The nurse correctly responds with which statements? (Select all that apply.)
    • A. 

      “There is no special preparation involved with this test since it is noninvasive.”

    • B. 

      “You should avoid any tranquilizers or sedatives the night before and the day of the test.”

    • C. 

      “You will need to sign a consent form for this test to be performed.”

    • D. 

      "You will have an IV inserted for the exam.”

    • E. 

      “I’m not really sure. The technician’s performing the test will let you know.”

  • 19. 
    The loss of neurons in the autonomic nervous system (ANS) of the older adult will cause the older adult to take longer to: (Select all that apply.)
    • A. 

      Recuperate from an illness.

    • B. 

      Apply brakes to stop a car.

    • C. 

      Form words into sentences.

    • D. 

      Climb stairs.

    • E. 

      Learn new material.

  • 20. 
    The nurse can be proactive in reducing neurologic injuries by: (Select all that apply.)
    • A. 

      Insisting everyone “buckle up” before starting the car.

    • B. 

      Encouraging children to wear bike helmets.

    • C. 

      Reminding swimmers to test water depth before diving.

    • D. 

      Encouraging use of hard hats at industrial sites.

    • E. 

      Discouraging recreational drug use that could bring on a stroke.

  • 21. 
    The FOUR (Full Outline of UnResponsiveness) tool is based on the assessment of the status of the: (Select all that apply.)
    • A. 

      Eye response.

    • B. 

      Motor response.

    • C. 

      Brainstem response.

    • D. 

      Respiratory function.

    • E. 

      Reflex response.

  • 22. 
    The nurse performs a reflex test on a newly admitted adult patient. The nurse runs a tongue blade along the sole of the foot and the patient responds with the great toe bending backward (upward) and the smaller toes fanning outward. The nurse suspects the patient may be suffering from what? (Select all that apply.)
    • A. 

      Injury to the CNS causing an abnormality in the motor control pathways leading from the cerebral cortex

    • B. 

      A myocardial infarction that has caused hypoxemia

    • C. 

      The influence of chemical substances

    • D. 

      Damage to the peripheral nervous system (PNS)

    • E. 

      Trauma to the hypothalamus

  • 23. 
    The nurse describes a concussion as a closed head injury in which:
    • A. 

      The brain tissue is bruised.

    • B. 

      No loss of consciousness occurs.

    • C. 

      There is amnesia related to the incident.

    • D. 

      There are no subsequent symptoms.

  • 24. 
    The nurse is aware that the older adult is more at risk for a cranial bleed following a head injury because the older adult has:
    • A. 

      A smaller brain, which allows for more movement inside the cranium.

    • B. 

      Fragile vessels more likely to rupture.

    • C. 

      Less cerebrospinal fluid to cushion the brain.

    • D. 

      Less flexibility of the meninges to absorb impact.

  • 25. 
    The emergency room nurse assessing clear drainage from the nose of a newly admitted patient with a head injury should perform which intervention?
    • A. 

      Document the presence of rhinorrhea.

    • B. 

      Inform the physician of the assessment.

    • C. 

      Test fluid with a glucose Accu-Chek or Dextrostix.

    • D. 

      Tape a drip pad under the nose.