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WorksheetsBoone's Exam 2
Total questions: 100
Worksheet time: 2hrs 40mins
A nurse is caring for a patient with an increase in ICP after a MVC. The nurse keeps the head of the bed elevated, keeps the lighting in the room low, keeps the door to the room shut, and turns the TV off in the room. The nurse understands that the reasoning behind this would be what?
Keep the electric bill of the hospital down.
Provide a safe environment for the patient.
Decrease stimulation for the patient.
This clusters care for the patient.
Neurologic assessment using a standardized numeric scale
MRI
Glascow Coma Scale
SAD PERSONS Scale
Electroencephalogram
Which Pharmacotherapy would be most appropriate for a patient with cerebral edema
insulin
MAO inhibitors
antianxlytic
osmotic diuretic
what would you suspect would be the problem with a patient who has sudden vomiting without nausea
epilepsy
increased cranial pressure
hypertension
cardiovascular ischemia
which is not a sign included in cushing's triad
tachycardia
changes in respiratory pattern
bradycardia
hypertension
which position is recommened for a patient with ICP
trendelenburgs
reverse trendelenburgs
head of bed at 30 degrees
prone
What should you teach the patient when it comes to bowel management to lower ICP?
Tell them to push hard
Tell them to stay constipated
Do not strain if become constipated
disease that results from the healthy liver tissue tissue being replaced with scar tissue
athrosclerosis
asthma
cirrhosis
psoriasis
A client being take care of in the ICU after a subdural hematoma has a blood pressure: 190/110, HR: 70, RR: 20 on a vent, and O2 sat.: 99% at 1000. During the 1100 assessment the vitals read at a blood pressure 200/100, HR: 58, RR: 20 on a vent, and O2 sat.: 99%. The nurse recognizes that this is a sign of what?
A decrease in ICP.
The patient is having a stroke.
The brain is compensating for an increase in ICP.
Imminent Death
Which of the following is a possible indication of head injury?
difficulty staying awake
loss of sensation in the hands
paralysis in some part of the body
Which trauma injury can cause spinal injury?
falls from height
arthritis
cancer
A clear fluid coming from the ears or nose is a sign of head injury.
True
False
The calculation for determining Cerebral Perfusion Pressure is which of the following?
MAP-ICP
ICP-BP
ICP-MAP
Systolic BP-Diastolic BP
A PaCO2 of greater than 40-45 would be considered which of the following?
Hypocapnia
Normal
Respiratory Acidosis
Hypercapnia
Which of the following would be considered a normal ICP?
0-10 mmHg
0-15 mmHg
10-25 mmHg
5-20 mmHg
Which of the following would be considered a normal CPP?
0-15 mmHg
75-95 mmHg
70-100mmHg
50-80mmHg
A client what has a CPP of less than 50 would be considered to have which of the following?
Irreversible brain damage
This is normal.
An improvement in their condition.
Herniation
The family of a client with a traumatic brain injury due to an ATV accident are asking what medications are being given to their family member. The RN knows which of the following medications would be given
Solumedrol
Mannitol
Furosemide
Normal Saline
The major concern with giving a diuretic to a client with a TBI would be?
Hypovolemic shock
Hypotension
increased urination
Electrolyte imbalance.
Signs of possible stroke include (Select all that apply)
Face Drooping
Arm Weakness
Speech Difficulty
Shuffling gait
Assessment/Diagnostics used for stroke patients include (Select all that apply)
EMG (Electromyography)
GCS (Glasgow Coma Scale)
NIHSS (National Institutes of Health Stroke Scale)
MEND (Miami Emergency Neurologic Deficit)
Evoked Potential Test
Which of the below is the most in-depth assessment tool for a stroke patient?
GCS (Glasgow Coma Scale)
NIHSS (National Institutes of Health Stroke Scale)
MEND (Miami Emergency Neurologic Deficit)
The most important modifiable risk factor for stroke is
Diabetes
Hypertension
Obesity
Poor diet
Which of the following are accurate statements about TIAs (Select all that apply)
1/3 do not experience another event
1/3 will have additional TIAs
1/3 will have a stroke
The symptoms of a TIA are different from a stroke
If you suspect a patient is having a TIA, monitor to see if symptoms disappear in a couple hours
True
False
Stroke due to occlusion of an artery where an infarction occurs is:
a hemorrhagic stoke
an ischemic stroke
a transient ischemic attack
The most common type of stroke is:
Embolic ischemic stroke
Intracerebral hemorrhagic stroke
Subarachnoid hemorrhagic stroke
Thrombotic ischemic stroke
You can easily tell by the symptoms whether the patient had an ischemic or hemorrhagic stroke
True
False
Motor deficits are on the opposite side of the body as to where the brain damage occurred
True
False
A form of aphasia where small words are omitted and short phrases take effort but make sense:
Expressive aphasia
Global aphasia
Receptive aphasia
Which of the following is true of dysarthria?
It affects the muscles that control speech
It occurs with receptive aphasia
It occurs with global aphasia
Which of the following is not an appropriate intervention for a patient with a hemorrhagic stroke?
Antiepileptics
Anticoagulants
Clipping
Coiling
Considerations for a pt with dysphagia following a stoke include which of the following (Select all that apply):
Assess LOC, gag reflex and swallowing ability
Avoid liquids or use thickeners
Perform mouth care before feeding
Place food on affected side of mouth
The term used for not seeing items on half of the visual field:
Diplopia
Homonymous hemianopsia
Myopia
Ptosis
Treat bladder control issues with which of the following (Select all that apply):
Ensure adequate fluid intake (mostly between 7 am and 7 pm)
Insert indwelling Foley catheter
Palpate for bladder distention
Toileting every 2 hours
What is a symptom of a stroke?
Hemiplegia of one body part
Aphasia of the face
Numbness of the hand
All of the above
What acronym can help you identify a stroke?
SLOW
FAST
STROKE
SLEEP
What are some common symptoms of a stroke?
Paralysis of one side of body, slurring speech, facial droop
Headache
Chest pain
Shortness of breath
What is a stroke?
Blocked blood vessel
Bleeding in the brain from a blood vessel
Loss of oxygen to part of the brain
All of the above
The letter F refer to Face in FAST acronym?
True
False
The letter A refer to Arm in FAST acronym
True
False
The letter S refer to speed in FAST acronym
true
false
The letter T refer to Time in FAST acronym
True
false
This patient would have a Stroke
True
False
Which of these are risk factors for stroke?
High blood pressure
Age > 55 years
Low cholesterol
Family history of stroke
All of the above
A stroke happens when
when there is enough oxygen getting to the brain.
when there is a lack of oxygen getting to the brain.
Both of them
Placing the object on the non-affected side of a TBI - stroke client would be helpful for a client who is experiencing which of the following?
Aphasia
Homonymous Hemianopsia
Apraxia
Diplopia
What are the three components of the Glasgow Coma Scale?
Eyes
Pain
Verbal
Motor
What is the lowest score a client can receive on the GCS?
0
3
2
1
You are assessing the GCS score in a 90-year-old trauma patient. Your patient's eyes open in response to speech, but is nonverbal and only appears to make localizing, purposeful movement towards painful stimuli. What's your best estimate of this patient's GCS score?
12
9
5
3
Your 72-year-old patient opens his eyes spontaneously, responds but is confused about time and place, and can follow physical commands correctly. What would you determine his GCS score to be?
14
8
3
10
Which of the following medications would the nurse consider a client with a RBC count of 3.0 to be taking?
Mannitol
Hydrochloroquine
Baclofen
Methotrexate
What is Rheumatoid Arthritis?
inflammation of the joints
inflammation of the muscles
inflammation of the skin
inflammation of the ankles
Rheumatoid Arthritis is curable.
true
false
What are synovial joints?
least common joints
most common joints
Weight loss is a sign and symptoms of RA.
true
false
Cracking our knuckles causes Rheumatoid Arthritis.
true
false
What side of the body does RA occur at?
both sides
one side
Where is RA most common?
in our hands
in our feet
in our elbows
in our knees
Arthritis caused by an autoimmune disorder.
osteoarthritis
rheumatoid arthritis
gout
bursitis
A client experiencing bilateral hand pain, nodules, weight loss, and a temperature of 100.4 F would be considered to have which disease?
Osteoarthritis
Sjogren Syndrome
Lupus
Rheumatoid Arthritis
A client diagnosed with RA complains to the nurse about the inflammation and pain. Which of the following actions would the nurse advise the client on? SATA
Warmth for inflammation
Cool for inflammation
Warmth for morning stiffness
Cool for morning stiffness
The client with RA asks the nurse for helpful ideas to assist with ADL's. Which of the following would be the best response by the nurse
Purchase styrofoam cups and plates.
Plan your day with rest periods.
Force yourself to perform tasks in a normal way.
Stay up later at night so you sleep later in the morning.
Symptoms of sickle cell include
Low red blood cell count
High red blood cell count
Recurrent infections
Periodic pain episodes
Nausea
Symptoms of Sickle Cell Anemia are caused by
premature break down of RBCs
stiff and inflexible RBCs get stuck in small blood vessels
oxygen deprivation (lack of) to organs
high blood pressure
A condition in which the blood doesn't have enough healthy red blood cells.
Anemia
Sickle Cell Anemia
Sickle Cell Trait
Episodes of Pain
Red Blood Cells
The sickle-shaped cells can also stick to vessel walls, causing a blockage that slows or stops the flow of blood. When this happens, oxygen can't reach nearby tissues. The lack of oxygen can cause ______.
Anemia
Sickle Cell Anemia
Sickle Cell Trait
Episodes of Pain
Red Blood Cells
Sickled cells live ___ days and healthy read blood cells live ___ days.
90 to 120 day; 10 to 20 days
10 to 20 days; 90 to 120 days
50 to 60 days; 200 to 500 days
200 to 500 days; 50 to 60 days
The lack of _____ can cause attacks of sudden, severe pain, called pain crises.
circulation
oxygen
carbon dioxide
red blood cells
blood
How can the symptoms of SCD be relieved? Select all that apply.
Pain Relivers
Antibiotics
There is no way to relieve symptoms.
Blood Transfusions
Immunizations (Shots)
Bone marrow suppression, production of fetal hemoglobin, risk for birth defects, and leukemia are the side effects of which of the following medications?
Prednisone
Methotraxate
Hydroxyurea
Ferumoxytol
The priority treatment for a patient who has sickle-cell disease is which of the following?
Oxygen administration
Prevent crisis
Blood transfusions
Pain management
When would the nurse notify the neurosurgeon immediately?
Client has a GCS of 11, from a 10.
Pin on a Halo device is detached.
Client states itching under the jacket.
Client has skin breakdown where the jacket is touching the skin.
Which of the following would be complications of a spinal cord injury?
Orthostatic Hypotension
Constipation
Aspiration
Anorexia
A graduate RN is educating a patient newly diagnosed with SLE. Which of the following should the RN include in her teaching plan?
Don't use make up to cover rash.
Apply powder to my rash.
Wash with mild soap.
Wear sunscreen outdoors
When treating a client with SLE, which of the following should be included in the treatment plan? SATA
Identify stressors
Monitor lab values
Avoid physical exercise.
Stop corticosteroids immediately if swelling occurs.
Vasopressin, Octreotide, Propanolol, IV Fluids and Blood Products would be expected treatments for what disease process?
Hepatic Encephalopathy
Ascites
Portal Hypertension
Esophogeal Varices
One of the main concerns with a patient diagnosed with cirrhosis would be which of the following?
Heart Failure
Bleeding
Kidney failure
Electrolyte imbalance
Which of the following would be an indication to perform a neuro assessment on a client?
Vomiting
Hypotension
Headache
Leg cramping
Interpret this EKG strip
Sinus Rhythm, Hr.70
Sinus Rhythm, Hr.90
Sinus Bradycardia, Hr.50
Sinus Tachycardia, Hr. 110
Interpret this Rhythm:
Normal sinus rhythm
Ventricular fibrillation
Sinus Brady with PAC's
Sinus Bradycardia
Which best describes this rhythm?
Atrial Fibrillation
Atrial Flutter
Asystole
PEA
Which best describes this rhythm?
Asystole
PEA
Pulseless Ventricular Tachycardia
Ventricular Fibrillation
Which best describes this rhythm?
Asystole
PEA
Ventricular Tachycardia
Ventricular fibrillation
Which best describes this rhythm?
Asystole
PEA
Ventricular Tachycardia
Ventricular fibrillation
Identify the waveform after the second heartbeat?
NSR with PAC
Sinus Tachycardia
NSR with PVC
Asystole
Identify the cardiac rhythm strip pictured above
Ventricular Tachycardia
Normal Sinus Rhythm
Atrial Fibrillation
Sinus Tachycardia
Benzodiazepines and Skeletal Muscle Relaxants are used for the treatment of which of the following? SATA
Cerebral Palsy
Seizures
Muscle Spasticity
Diabetes
A client who is receiving TPA begins to bleed from their rectum. Which order would the nurse follow for this problem?
Obtain, Assess, Draw, Contact
Contact, Obtain, Assess, Draw
Assess, Obtain, Contact, Draw
Draw, Assess, Obtain, Contact
The family of a client with Cerebral Palsy is concerned about what they should watch for with their family member. The biggest risk factor for CP is which of the following?
Aspiration
Safety
Mobility
Bleeding
A client diagnosed with hepatic encephalopathy should have which of the following included in their care plan?
Avoid medications that can alter the LOC.
Independence
Orthostatic Hypotension
Atelectasis
what is spastic cerebral palsy
the muscles are stiff and tight making it difficult to move and reducing the range of movement that's possible
when a person has balance and co-ordination problems, resulting in shaky or clumsy movements and sometimes tremors
or none of the above
What is the most common type of Cerebral Palsy?
(a)
What are some symptoms of cerebral palsy?
Baby doesn't roll over in either direction
Baby cannot bring her hands together
Baby has difficulty bringing her hands to mouth
All of the above
Some kids with cerebral palsy will have trouble with motor skills. Which of the following is an example of a motor skill?
Learning how to read
Lifting a fork to one's mouth
Staying quiet in class
Learning how to run
For kids with cerebral palsy, physical therapy:
Can permanently cure their condition
Isn't much help at all
Prevents their symptoms from spreading
Can help manage their symptoms
