Transcript Rebecca`s Final test Answers

How you were Graded
PN 141 Neuro/Sensory
Rebecca Maier, BSN
December 2014
Quiz 2 – ATI Intro
to Pharmacology
Modules
Handed out
11/24 due 11/25
Part 1 - 77.3%
104”
60, 80, 92
Part 2 - 76%
84”
Test 2
ATI Intro to
Pharmacology
Test – max take x 3 –
Handed out 11/25
due 12/1
92% - P1
76% - P2
168 ÷ 2=
84%
153.3÷ 2=
76.6%
Final
PN 141 Neuro/Sensory
Rebecca Maier, BSN
December 2014
The nurse is aware that the patient has 20/40 vision. This means that the
patient can see at 20 feet what the normal eye can see at _______ feet.
1.
a.
b.
c.
d.
10
20
30
40
1.
ANS:
D
The Snellen Eye Chart tests visual acuity. A vision evaluation of 20/40 means that the
patient can see at 20 feet what the person with normal vision can see at 40 feet.
PTS:
2
DIF:
Cognitive Level: Application
REF:AHN
Page 608 (T13-2), 609;
Review slide 3
Snellen evaluation
KEY:
Nursing Process
OBJ:
7
TOP:
Step: I Assessment
MSC:
NCLEX: Physiological Integrity
The patient tells the nurse that he is legally blind. This information
provides the nurse with which information to use in planning care?
2.
a.
No vision enhancement techniques would be appropriate for this patient, because he is totally blind.
b.
c.
This patient probably has some light perception, but no usable vision.
This patient has some usable vision, which enables him to function at an acceptable level.
d.
Further questioning is needed to determine how this patient’s visual impairment affects his normal functioning.
2.
ANS:
D
“Legal blindness” refers to individuals with a maximum visual acuity of 20/200 with
corrective eyewear and/or visual field sight capacity reduced by 20 degrees.
Categories have been established to help determine the exact extent of the vision
loss and what assistive measures are appropriate for the individual. The nurse will
need more information as to the exact extent of the vision loss for this patient.
PTS:
2
DIF:
Cognitive Level: Analysis
607-611
;
Review slide 4
OBJ:
6
TOP:
Blindness
KEY:
Planning
MSC:
NCLEX: Physiological Integrity
REF: AHN
Page
Nursing Process Step:
A patient has a head injury and is presenting with signs and symptoms
of increased intracranial pressure. Which nursing intervention would be helpful
a. Place the neck in a neutral position to promote venous drainage.
in reducing this pressure?
3.
3.
ANS: A
b. Suction hourly to stimulate the cough reflex.
c. Add extra blankets to keep the patient warm.
d. Turn the patient frequently to prevent skin impairment.
Place the neck in a neutral position (not flexed or extended) to
promote venous drainage. HOB 30 -45 degrees
PTS: 2
DIF: Cognitive Level: Application REF:
Page 671 column 2
;
668 -670 Review slide 27
OBJ: 13
TOP: Intracranial pressure (ICP) KEY:
Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
AHN
4.
What does a tympanoplasty correct?
a.
b.
c.
d.
Conductive hearing loss
Sensorineural hearing loss
Congenital hearing loss
Functional hearing loss
4.
ANS: A
Tympanoplasty can correct a conductive hearing
loss.
PTS: 2
DIF: Cognitive Level: Knowledge
REF:AHN Page 644 ; 644-645
Review slide 20
OBJ: 17 TOP: Tympanoplasty
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
What is the cardinal sign of increased intracranial pressure in a
brain injured patient? a. Pupil changes
5.
b. Ipsilateral paralysis
c.
Vomiting
5.
ANS: D d. Decrease in the level of consciousness
Collection of objective data includes a change in level of
consciousness. A change in the level of consciousness is
the earliest sign of increased intracranial pressure.
PTS: 2
DIF: Cognitive Level: Analysis
REF: AHN Page 669;
review slide 26
OBJ: 12
TOP: Intracranial pressure (ICP) KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
Four hours after a stapedectomy the patient complains that hearing has
not improved at all. What knowledge would the nurse use to shape a response?
6.
a.
b.
c.
d.
A large percentage of stapedectomies are not successful
It will take at least 10 days for the graft to heal
Hearing will not return until edema subsides
Hearing will improve after irrigation of the ear
6.
ANS: C
Hearing improvement will not be noted until edema
subsides and the packing is removed.
PTS: 2
DIF: Cognitive Level: Application
REF:AHN Page 644 review slide 18
OBJ: 17 TOP: Stapedectomy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
A patient is scheduled for a stapedectomy. Appropriate
postoperative teaching should include which of the following?
7.
a.
b.
c.
d.
Hourly changing cotton from external ear canal
Gently blowing both nares simultaneously
Teaching patient to open mouth when sneezing or coughing
Limiting activities for 3 weeks
7.
ANS: C
The nurse must include patient teaching about opening
the mouth when sneezing or coughing or blowing the
nose gently on one side at a time for 1 week.
PTS: 2
DIF: Cognitive Level: Analysis
REF:AHN
Page 644 | Patient
Teaching Box; Review slide 18
OBJ: 19
TOP: Stapedectomy
KEY: Nursing Process Step: Implementation
NCLEX: Physiological Integrity
.
MSC:
A patient, age 45, is to have a myelogram to confirm the presence of a
herniated intervertebral disk. Which nursing action should be planned for her
with respect to this diagnostic test?
8.
a.
b.
c.
d.
Obtain an allergy history before the test.
Place her in a flat position after the test.
Warn her that paralysis could result from injection of the contrast medium.
Keep her NPO for 6-8 hours after the test.
8.
ANS: A
Before the dye is injected, patients must be asked
whether they have any allergies, specifically whether they
have had any anaphylactic or hypotensive episodes from
other dyes.
PTS: 2
DIF: Cognitive Level: Analysis
REF: AHN Page 664 , 115;Review slide 33
OBJ: 4
TOP: Diagnostic procedures
KEY:
Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
When the newly blind male home health patient asks the nurse how he
might get assistance, who might the nurse suggest he contact?
9.
a.
b.
c.
d.
American Red Cross
American Foundation for the Blind for a list of agencies
Local hospital social worker
The public health department
9.
ANS: B
The American Foundation for the Blind has lists of
agencies to assist and educate the visually impaired
patient.
PTS: 2
DIF: Cognitive Level: Analysis
REF:AHN
Page 607-610; Review slide 4
OBJ: 15
TOP: Medications KEY: Nursing Process
Step: Implementation
MSC: NCLEX: Physiological Integrity
10.
What are surgical navigational systems?
a.
b.
c.
d.
Computerized devices that guide the surgeon
A set of detailed anatomic maps pinpointing specific areas of the brain
A written set of progressive processes for the resection of small brain tumors
The use of radioactive materials to pinpoint small tumors of the brain
10. ANS: A
Surgical navigational systems are computerized devices
that guide the surgeon and make possible the resection
of tumors that were once thought to be inoperable.
PTS: 2
DIF: Cognitive Level: Comprehension
REF: Video from Power point;
Review Slide 37
OBJ: 30
TOP: Hematoma KEY: Nursing Process
Step: Planning
MSC: NCLEX: Physiological Integrity
11.
What does the cataract treatment of phacoemulsification involve?
a.
b.
c.
d.
“Drying” the cataract with hypertonic saline
Removing the lens through the anterior capsule
The insertion of a new lens
Breaking the cataract with ultrasound
11. ANS: D
Phacoemulsification uses ultrasound to break up
the cataract.
PTS: 2 DIF:
Cognitive Level: Analysis
REF:AHN Page 617 Col. 2; 617-618f
.
Review slide 6
OBJ: 11 TOP: Infectious/inflammatory disorders
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
A patient has an infectious/inflammatory process of the eyelid.
The primary goal of nursing intervention is
12.
a.
b.
c.
d.
administering antibiotics.
flushing the eye with sterile ophthalmic solution.
maintaining bedrest.
preventing further infection.
12. ANS: D
A primary objective of nursing care for the patient with
an infectious or inflammatory process of the eyelids is
prevention of the spread of infection.
PTS: 2
DIF: Cognitive Level: Analysis
REF:AHN Page 613-614; Review slide 9 ;
Power Point Day 2 – slide 40-43
OBJ: 8
TOP: Infectious/inflammatory disorders
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
A patient has been complaining of headaches. Which of the following
would the nurse expect to happen if these were migraine headaches?
13.
a.
b.
c.
d.
They are observed during times of stress.
They become worse toward evening.
They have their onset when the person is in his or her twenties or thirties.
They cause unusual smells or sounds for the patient before the pain begins.
13.
ANS: D
Migraine headaches are unusual in that there are prodromal
(early signs and symptoms of a developing condition or
disease) signs and symptoms that occur before the acute
attack.
PTS:
2
DIF: Cognitive Level: Analysis
REF:AHN Page 665 Col. 1 last Para
.
Review slide 29
OBJ: 9
TOP: Headaches KEY: Nursing Process
Step: Assessment
MSC: NCLEX: Physiological Integrity
14.
What does diabetes retinopathy result from?
a.
b.
c.
d.
Capillaries in retina hemorrhage
Long-term overdosing of insulin
Retinal detachment
Aging
14. ANS: A
Retinopathy is caused when the capillaries in the retina
have aneurysms or hemorrhage.
PTS: 2
.
DIF: Cognitive Level: Comprehension
REF:AHN
Page 618; 526, 618 -620;
Review slide 7
OBJ: 9
TOP: Glaucoma KEY: Nursing Process
Step: Assessment
MSC: NCLEX: Physiological Integrity
What is the nurse assessing when asking the patient, “Who is the
president of the United States?” during a level of consciousness assessment?
15.
a.
b.
c.
d.
Orientation
Memory
Calculation
Fund of knowledge
15. ANS: D
Fund of knowledge is tested by questions such as “Who is
the president?” or asking about current events.
PTS: 2
.
DIF: Cognitive Level: Comprehension
REF:AHN
Page 658; 658-659,
Review slide 23
OBJ: 9
TOP: Level of Consciousness
KEY: Nursing Process Step: Implementation
MSC:
NCLEX: Physiological Integrity
The nurse will assess for _____________ when the older adult home health
patient complains that the entire right side of his head hurts and he cannot chew without pain.
16.
a.
b.
c.
d.
mumps
external otitis
otitis media
labyrinthitis
16. ANS: B
The symptoms of painful head, painful chewing, and pain
when the auricle is moved all indicate external otitis,
frequently caused by compacted cerumen.
PTS: 2
DIF: Cognitive Level: Knowledge
REF:AHN Page 635 ; 635-640
PPT day 3 slides 27-31 (30); Review slide 14
OBJ: 16
TOP: External otitis
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
17.
Most patients with Ménière’s disease are treated with
a.
b.
c.
d.
surgery.
diuretics.
hearing aids.
analgesics.
17. ANS: B
Fluid restriction, diuretics, and a low-salt diet are
prescribed in an attempt to decrease fluid pressure.
PTS: 2
.
DIF: Cognitive Level: Knowledge
REF:AHN Page 641 ; 641-644
PPT day3 slides 56-65; Review slide 15
OBJ: 15 TOP: Ménière’s disease
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological
A patient, age 23, has a comminuted fracture of T6-T7. She has a spinal cord injury
resulting in paraplegia. She manifests signs and symptoms of autonomic dysreflexia,
which is frequently triggered by a. bladder distention.
18.
b. defecation reflexes.
c. postural changes.
d. electrolyte imbalance.
18.
ANS: A
Autonomic dysreflexia occurs as a result of abnormal cardiovascular
response to stimulation of the sympathetic division of the autonomic
nervous system as a result of stimulation of the bladder, large
intestine, or other visceral organs. The most common cause of this
condition includes a distended bladder or fecal impaction.
PTS:
.
OBJ:
KEY:
MSC:
2
DIF:
Cognitive Level: Analysis
REF:AHN
Page 710 Col.2 Par. 3
|
Page 145-147; 710-714; Review slide 35
10
TOP: Spinal cord injury
Nursing Process Step: Assessment
NCLEX: Physiological Integrity
What should the nurse advise the 20-year-old to do who has been put on
cefaclor (Ceclor) for a resistant otitis media?
19.
a.
b.
c.
d.
Store suspension at room temperature
Discontinue drug when symptoms abate
Avoid alcoholic beverages
Take with meals only
19. ANS: C
Drinking alcohol is discouraged while on Ceclor. The drug
should be taken in its entirety and stored in the
refrigerator. The drug can be taken with or without meals.
PTS: 2
DIF: Cognitive Level: Knowledge
REF:AHN
Page 637, Table 13-5
Pages 636-638; Review slide 14
OBJ: 16
TOP: Ceclor KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity
A patient with a spinal cord injury at T1 complains of stuffiness of the
nose and a headache. The nurse notes a flushing of the neck and “goose flesh.”
What should be the primary nursing intervention based on these assessments?
20.
a.
b.
c.
d.
Place patient in flat position and check temperature
Administer oxygen and check oxygen saturation
Place on side and check for leg swelling
Sit upright and check blood pressure
20.
ANS:
D
These are indicators of autonomic dysreflexia or hyperreflexia. It is a medical
emergency. The patient should be placed in an upright position to decrease
blood pressure and the blood pressure should be checked. Assessments for
impaction, full bladder, or a urine infection can help to evaluate this condition.
PTS:
OBJ:
KEY:
MSC:
2
DIF:
Cognitive Level: Analysis
REF:AHN Page 712 Box 14-4;
.
pages 710, 712; review slide 35
20
TOP:
Dysreflexia
Nursing Process Step: Intervention
NCLEX: Physiological Integrity
21.
What do miotic eyedrops do for a patient with glaucoma?
a.
b.
c.
d.
Dilate the pupil and sharpen vision
Lubricate and moisten the dry eye
Irrigate the surface of the eye
Constrict the pupil and open the canal of Schlemm
21. ANS: D
Miotic eyedrops allow the pupil to constrict and
open the canal of Schlemm to drain the excess fluid.
PTS: 2
DIF: Cognitive Level: Application
REF: AHN Page 625; 623-627
Review slide 8
OBJ: 4
TOP: Aging KEY:Nursing Process
Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment
22.
When the eye adjusts to seeing objects at various distances, it is called
a.
b.
c.
d.
PERRLA.
refraction.
focusing.
accommodation.
22. ANS: D
Accommodation: The eye is able to focus on objects
at various distances.
PTS: 2
DIF: Cognitive Level: Application
REF:AHN Page 604 (#2);
.
Review slides 2 and 3
OBJ: 7
TOP: Aging KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Safe | Effective Care Environment
A patient, age 27, has been admitted to the neurological department
because of seizures of unknown cause. The nurse should take precautions by
23.
a.
b.
c.
d.
placing the patient in protective restraints.
being certain padded side rails are present.
suggesting that the family monitor the patient.
placing the patient with one-on-one nursing service.
23. ANS: B
Padded side rails may be used, especially if seizures
often occur during sleep.
PTS: 2
DIF: Cognitive Level: Application
REF:AHN Page 679;
.
Pages 676-680; Review slide 39
OBJ: 10 TOP: Seizures KEY: Nursing Process
Step: Planning
MSC: NCLEX: Safe | Effective Care Environment
A patient who had an enucleation of the right eye has been admitted PACU.
What should the nurse include in the plan of care?
24.
a.
b.
c.
d.
Turn, cough, and deep breathe every 3 hours
Apply a pressure dressing over the right eye socket
Document dressing assessment every 2 hours
Turn on the affected side
24. ANS: B
A pressure dressing will be applied to the right eye
socket and the dressing should be checked every
hour for the first 24 hours.
PTS: 2
DIF: Cognitive Level: Application
REF:AHN Page 629; Review slide 11
OBJ: 11 TOP: Infections/inflammatory disorders
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
The newly admitted patient to the emergency room after a motorcycle
accident has serosanguineous drainage coming from the nose. What is the most
appropriate nursing response to this assessment? a. Cleanse nose with a soft cotton-tipped swab
25.
b. Gently suction the nasal cavity
c. Gently wipe nose with absorbent gauze
d. Ask patient to blow his nose
25.
ANS: C
The patient’s ear and nose are checked carefully for signs of blood and
serous drainage, which indicate that the meninges are torn and spinal
fluid is escaping. No attempt should be made to clean out the orifice
or to blow the nose. The drainage can be wiped away. The drainage
can be tested for the presence of glucose, which would confirm that
the fluid is spinal fluid and not mucus.
PTS:
2
DIF:
Cognitive Level: Application
REF:AHN
Page 709; Review slide 25
TOP: Trauma KEY:
Nursing Process Step:
OBJ: 20
Implementation
MSC: NCLEX: Physiological Integrity
How would the nurse explain the purpose of photocoagulation
to a diabetic patient with diabetic retinopathy?
26.
a.
b.
c.
d.
The procedure will destroy the retina, which is not getting enough blood supply.
The procedure will reduce edema in the macula of the eye.
The procedure will vaporize fatty deposits that appear in the retina.
The procedure will destroy new blood vessels, seal leaking vessels, and help
prevent retinal edema.
26. ANS: D
Photocoagulation is useful in diabetic retinopathy
to cauterize hemorrhaging vessels and to destroy
new vessels.
PTS: 2
DIF: Cognitive Level: Analysis
REF:AHN Page 630; Review slide 7
OBJ: 9
TOP: Diabetic retinopathy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
The patient, age 62, has had insulin-dependent diabetes mellitus for 20 years
and has symptoms of proliferate diabetic retinopathy. He is scheduled for his first
panretinal photocoagulation treatment. The nurse explains to him that the purpose
of this procedure is to
a. destroy the retina, which is not getting enough blood supply.
27.
b. reduce edema in the macula of the eye.
c. vaporize fatty deposits that appear in the retina.
d. destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.
27. ANS: D
Photocoagulation is useful in diabetic retinopathy
to cauterize hemorrhaging vessels.
PTS: 2
DIF: Cognitive Level: Analysis
REF:AHN Page 630; Review slide 7
OBJ: 6
TOP: Diabetic retinopathy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
28.
A lumbar puncture is performed to obtain which specimen?
a.
b.
c.
d.
Serum
Cerebral spinal fluid (CSF)
Urine
Arterial blood gases
28. ANS: B
A lumbar puncture is done to obtain CSF for examination,
to relieve pressure, or to introduce dye or medication.
PTS: 2
DIF: Cognitive Level: Knowledge
REF:AHN Page 661; Review slide 40
Pages 661-662
OBJ: 12
TOP: Lumbar puncture
KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
29.
Why is otitis media found more frequently in children 6 to 36 months?
a.
b.
c.
d.
Eustachian tubes in children are shorter and straighter.
Infection descends via the eustachian tube to the throat.
Children’s eustachian tubes are more vertical and longer.
Otitis media is seen equally in both children and adults.
29. ANS: A
Children’s shorter and straighter eustachian tubes
provide easier access of the organisms from the
nasopharynx to travel to the middle ear.
PTS: 2
DIF: Cognitive Level: Analysis
REF:AHN Page 636 Review slide 14
OBJ: 16 TOP: Otitis media
KEY: Nursing Process
Step: Evaluation
MSC: NCLEX: Physiological Integrity
What should the nurse do when the child arrives on the floor with the
diagnosis of bacterial meningitis?
30.
a.
b.
c.
d.
Arrange for humidified oxygen per mask
Place the child in respiratory isolation
Inquire about drug allergy
Hold NPO until orders arrive
30. ANS: B
Persons with bacterial meningitis are placed in respiratory
isolation until the pathogen can no longer be cultured,
usually 24 hours.
PTS: 2
DIF: Cognitive Level: Comprehension
REF:AHN Page 704; 704-705
Review slide 40
OBJ: 18
TOP: Bacterial meningitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
The nurse counsels the 16-year-old boy that playing his music
at high volume can result in impairment in hearing related to:
31.
a.
b.
c.
d.
damaged tympanic membrane.
protective buildup of cerumen.
damage of the fine hair cells in the organ of Corti.
rupture of the oval window.
31.
ANS: C
Long-term exposure to loud noises can damage the fine hair
cells in the organ of Corti, which causes a conductive hearing
loss.
PTS:
2
DIF: Cognitive Level: Knowledge
REF:AHN
Page633 Col. 2 Par 2;
.
Pages 633-635; Review slide 13
OBJ: 12
TOP: Health promotion
KEY:
Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
When obtaining a health history from a patient with a neurological problem,
the nurse is likely to elicit the most valid response from the patient with which question?
32.
a.
b.
c.
d.
“Do you have any sensations of pins and needles in your feet?”
“Does the pain radiate from your back into your legs?”
“Can you describe the sensations you are having in your head?”
“Do you ever have any nausea or dizziness?”
32. ANS: C
For patients with suspected neurological conditions,
the presence of many symptoms or subjective data
may be significant.
PTS: 2
DIF: Cognitive Level: Application
REF: Review slide 41;Quiz 1 question 7
OBJ: 9
TOP: AssessmentKEY: Nursing Process
Step: Assessment
MSC: NCLEX: Physiological Integrity
The patient tells the nurse that he is legally blind. This information provides
the nurse with which information to use in planning care?
33.
a.
b.
c.
d.
No vision enhancement techniques would be appropriate for this patient, because he is totally
blind.
This patient probably has some light perception, but no usable vision.
This patient has some usable vision, which enables him to function at an acceptable level.
Further questioning is needed to determine how this patient’s visual impairment affects his
normal functioning.
33.
ANS:
D
“Legal blindness” refers to individuals with a maximum visual acuity of 20/200 with
corrective eyewear and/or visual field sight capacity reduced by 20 degrees. Categories
have been established to help determine the exact extent of the vision loss and what
assistive measures are appropriate for the individual. The nurse will need more
information as to the exact extent of the vision loss for this patient.
PTS:
2
DIF:
Cognitive Level: Analysis
REF:AHN Page 609 | Page 607-610;
Review slide 4
OBJ:
6
TOP:
Blindness KEY:
MSC:
NCLEX: Physiological Integrity
.
Nursing Process Step: Planning
Why is the patient with suspected Guillain-Barre Syndrome (GBS)
hospitalized immediately? a. The infection needs to be treated with IV antibiotics to prevent paralysis
34.
b. The brain may swell quickly causing seizures
c. The disease can rapidly progress into respiratory failure
d. IV hydration is needed to prevent possible fatal hypotension
34. ANS: C
Hospitalization is necessary for GBS patients because the
disease progresses very quickly and respiratory failure
may occur.
PTS: 2
DIF: Cognitive Level: Analysis
REF:AHN
Page703; 703-704
Review slide 40
OBJ: 18
TOP: Guillain-Barre
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
KEY:
Which question is likely to elicit the most valid response from the patient
who is being interviewed about a neurologic problem?
35.
a.
b.
c.
d.
“Do you have any sensations of pins and needles in your feet?”
“Does the pain radiate from your back into your legs?”
“Can you describe the sensations you are having?”
“Do you ever have any nausea or dizziness?”
35.
ANS: C
For patients with suspected neurologic conditions, the
presence of many symptoms or subjective data may be
significant. Offering leading questions is not beneficial and
may allow the patient to give misinformation. Questions
should be specific about symptoms.
PTS:
2
DIF: Cognitive Level: Application
REF: Review slide 41; Quiz 1 question 7
OBJ: 8
TOP: Assessment KEY: Nursing Process
Step: Assessment
MSC: NCLEX: Physiological Integrity
A patient, age 45, is to have a myelogram to confirm the presence of a
herniated intervertebral disk. Which nursing action should be planned for her with
respect to this diagnostic test? a. Obtain an allergy history before the test.
36.
b. Place her in a flat position after the test.
c. Warn her that paralysis could result from injection of the contrast medium.
d. Keep her NPO for 6-8 hours after the test.
36. ANS: A
Before the dye is injected, patients must be asked
whether they have any allergies, specifically whether they
have had any anaphylactic or hypotensive episodes from
other dyes.
PTS: 2
DIF: Cognitive Level: Analysis
REF:AHN Page 664; Review slide 33
OBJ: 4
TOP: Diagnostic procedures
KEY: Nursing Process
Step: Planning
MSC: NCLEX: Physiological Integrity
37.
Sjögren’s syndrome is associated with which eye disorder?
a.
b.
c.
d.
Keratoconjunctivitis sicca
Conjunctivitis
Blepharitis
Opaque lens disorder
37. ANS: A
If the patient with keratoconjunctivitis sicca has
associated dry mouth, the patient has Sjögren’s
syndrome.
PTS: 2
DIF: Cognitive Level: Application
REF:AHN Page 615-616
Review slide 10
OBJ: 4
TOP: Dry eye disorders
KEY: Nursing Process
Step: Assessment
MSC: NCLEX: Physiological Integrity
38.
What is the reticular activating system (RAS) essential to? (Select all that apply.)
a.
b.
c.
d.
e.
Concentration
Wakefulness
Speech
Attention
Memory
f. Introspection
38. ANS: A, B, D, F - sorry
The RAS, located on the brainstem, is essential to
wakefulness, attention, concentration, and introspection.
PTS: 2
DIF: Cognitive Level: Analysis
REF: Review slide 24
OBJ: 1
TOP: reticular activating system
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
A patient, age 45, is to have a myelogram to confirm the presence of a herniated
intervertebral disk. Which nursing action should be planned with respect to this diagnostic
test?
a. Obtain an allergy history before the test.
39.
b. Ambulate the patient when returned to the room after the test.
c. Use heated blanket to keep patient warm after procedure.
d. Keep NPO for 6 to 8 hours after the test.
39.
ANS: A
Before the dye is injected, patients must be asked whether
they have any allergies, specifically whether they have had
any anaphylactic or hypotensive episodes from other dyes.
PTS:
2
DIF: Cognitive Level: Application
REF:AHN
Page 664
Review slide 33
OBJ: 11
TOP: Diagnostic procedures
KEY: Nursing Process
Step: Planning
MSC: NCLEX: Physiological Integrity
A patient has been diagnosed with organic brain pathology. He is presenting
with signs and symptoms of total or partial loss of the ability to recognize familiar objects or
people through sensory stimulation. This condition is called
40.
a.
b.
c.
d.
apraxia.
agnosia.
aphasia.
dysphagia.
40.
ANS:
B
Agnosia is a total or partial loss of the ability to recognize familiar objects or
people through sensory stimuli as a result of organic brain damage.
a.
apraxia. – pg 689
b.
agnosia.- pg 675
c.
aphasia. – pg 659
d.
dysphagia. – pg 189
PTS:
2
DIF:
REF:
Cognitive Level: Comprehension
AHN Page 675
Review slide 38
Organic brain pathology KEY:
OBJ:
16
TOP:
Step: Assessment
MSC: NCLEX: Physiological Integrity
Nursing Process
A patient is prescribed eyedrops that constrict the pupil, permitting aqueous
humor to flow. The nurse would reinforce the teaching by referring to the drops as
41.
a.
b.
c.
d.
mydriatics.
miotics.
osmotics.
inhibitors.
41. ANS: B
Miotics are agents that cause the pupil to contract
or constrict.
PTS: 2
DIF: Cognitive Level: Analysis
REF:AHN Page 625
Review slide 8
OBJ: 9
TOP: Medications
KEY: Nursing
Process Step: Implementation
MSC: NCLEX: Physiological Integrity
A family member of a patient who has just suffered a tonic-clonic seizure
is concerned about the patient’s deep sleep. What is this behavior called?
42.
a.
b.
c.
d.
Convalescent period
Neural recovery period
Sombulant period
Postictal period
42. ANS: D
Seizures are followed by a rest period of variable
length, called a postictal period.
PTS: 2
DIF: Cognitive Level: Knowledge
REF:AHN Page676
Page 676-680
Review slide 39
OBJ: 14 TOP: Seizures KEY: Nursing Process
Step: Implementation
MSC: NCLEX: Physiological Integrity
Ergotamine tartrate medications are beneficial in migraine headaches
because they
a. dilate cerebral blood vessels.
43.
b. constrict cerebral blood vessels.
c. reduce neurotransmission of pain impulses.
d. enhance endorphin secretion.
43.
ANS: B
Ergotamine tartrate preparations act by constricting the cerebral blood
vessel’s walls and reducing cerebral blood flow. These cause reduced
inflammation and may reduce pain transmission.
PTS:
2
TOP:
DIF:
Cognitive Level: Comprehension
REF: Review slide 30 only
Page 665-669 – Rx but does not list this med
Medications
KEY:
Nursing Process Step: Implementation
MSC:
NCLEX: Physiological Integrity
A patient has a family history of cataracts. He asks what symptom would
be present if he begins to develop them. The nurse might respond that the first symptom
of a cataract is usually
a. pain in the eyes.
44.
b. blurring of vision.
c. loss of peripheral vision.
d. dry eyes.
44. ANS: B
Blurring of vision is often the first subjective
symptom reported by a patient who has cataracts.
PTS: 2
DIF: Cognitive Level: Application
REF:AHN Page 617 Review slide 6
OBJ: 9
TOP: Cataracts KEY: Nursing Process
Step: Implementation
MSC: NCLEX: Physiological Integrity
The nurse assures an anxious family member of a 92-year-old patient who
is demonstrating signs of dementia that many causes of dementia are reversible and
a. Hypotension
preventable. What is one example?
45.
b. Alzheimer disease
c. Diabetes
d. Parkinson disease
45.
ANS: A
Some forms of dementia are reversible. Dementia caused by
hypotension, anemia, drug toxicity, metabolic disturbance,
and malnutrition can all be corrected to abolish the dementia.
PTS:
2
DIF: Cognitive Level: Application
REF: You have to choose the least bad answer
OBJ: 17
TOP: Causes of dementia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
A patient, age 23, has a comminuted fracture of T6-T7. She has a spinal
cord injury resulting in paraplegia. She manifests signs and symptoms of autonomic
dysreflexia, which is frequently triggered by a. bladder distention.
46.
b. defecation reflexes.
c. postural changes.
d. electrolyte imbalance.
46.
ANS: A
Autonomic dysreflexia occurs as a result of abnormal cardiovascular
response to stimulation of the sympathetic division of the autonomic
nervous system as a result of stimulation of the bladder, large
intestine, or other visceral organs. The most common cause of this
condition includes a distended bladder or fecal impaction.
PTS:
OBJ:
MSC:
2
DIF:
Cognitive Level: Analysis
REF:AHN Page 710 | Page 710-712
Review slide 35
10
TOP: Spinal cord injury
Nursing Process Step: Assessment
NCLEX: Physiological Integrity
KEY:
47.
Astigmatism is a medical term meaning which visual disorder?
47. ANS: A
Astigmatism—blurred vision.
PTS: 2
a.
b.
c.
d.
Blurred vision
Inability to detect colors
Color blindness
Farsightedness
DIF: Cognitive Level: Knowledge
REF:AHN Page 611 | Table 13-3
Page 608-609, 611; Review slide 3
OBJ: 4
TOP: Visual acuity
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
48.
What is the nurse aware of when assessing a person with a craniocerebral injury?
a.
b.
c.
d.
Most injuries of this type are irreversible
Open injuries are always more serious than closed injuries
Signs and symptoms may not occur until several days after the trauma
Trauma to the frontal lobe is more significant than to any other area
48.
ANS: C
If a patient who has been conscious for several days after
head injury loses consciousness or develops neurologic signs
and symptoms, a subdural hematoma should be suspected.
PTS:
2
DIF: Cognitive Level: Analysis
REF:AHN
Page:709 Col1 Para 2
Pages 708-710; Review slide 25
OBJ: 19
TOP: Trauma
KEY: Nursing Process
Step: Assessment
MSC: NCLEX: Physiological Integrity
A patient, age 69, is being evaluated by a neurologist for signs
of muscle rigidity, masklike face (area from forehead to chin), and propulsive gait.
These signs are often characteristic of
a. multiple sclerosis.
49.
b. Parkinsonism.
c. Alzheimer’s disease.
d. epilepsy.
49.
ANS: B
Parkinsonism is a syndrome that consists of a slowing down in
the initiation and execution of movement (bradykinesia),
increased muscle tone (rigidity), tremor, and impaired
postural reflexes.
PTS:
2
DIF: Cognitive Level: Analysis
REF:AHN Page 685
Pages 683-688; Review slide 38
OBJ: 16
TOP: Parkinsonism
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
A patient, age 76, is partially blind. His physician has diagnosed open-angle
glaucoma. The goal of treatment in glaucoma is to
50.
a.
b.
c.
d.
decrease aqueous humor.
increase aqueous humor.
decrease discomfort.
restore vision.
50.
ANS: A
A beta-blocker, such as Betoptic, will reduce intraocular
pressure. Miotics such as pilocarpine constrict the pupil and
draw the iris away from the cornea, allowing aqueous humor
to drain out of the canal of Schlemm.
PTS:
2
DIF: Cognitive Level: Analysis
REF:AHN Page;625 Page 623 - 627 |
Page 625-626 Medications Table; Review slide 8
OBJ: 7
TOP: Glaucoma
KEY: Nursing Process
Step: Planning
MSC: NCLEX: Physiological Integrity