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WorksheetsMed Surg: neuro part 1 quiz, 35 min
Total questions: 22
Worksheet time: 33mins
The nurse is assessing a patient with suspected increased intracranial pressure (IICP). Which of the following findings would the nurse expect to observe?
Irregular respirations, bradycardia, and widened pulse pressure
Hypotension, tachycardia, and rapid respirations
Pinpoint pupils, tachypnea, and hypertension
Polyuria, hyperreflexia, and bounding pulses
Which assessment finding is an early sign of increased intracranial pressure (IICP)?
Cushing’s triad
Restlessness and confusion
Fixed and dilated pupils
Decerebrate posturing
A client with severe traumatic brain injury is admitted with increased intracranial pressure. Which nursing action is the priority?
Elevate the head of the bed 30 degrees
Encourage coughing and deep breathing
Maintain client in Trendelenburg position
Suction frequently and vigorously
The nurse is planning care for a patient with increased intracranial pressure. Which intervention should be avoided?
Administering stool softeners as prescribed
Clustering nursing care to allow rest periods
Maintaining neck in a midline position
Providing range-of-motion exercises
The nurse teaches a family how to help prevent further increases in ICP for a client recovering from head trauma. Which instructions are appropriate? Select all that apply.
Avoid hip and neck flexion when positioning the client
Encourage frequent coughing to clear secretions
Keep the environment calm and quiet
Administer stool softeners as prescribed
Position the client flat to promote cerebral perfusion
A nurse is assessing a client using the Glasgow Coma Scale. Which three responses are evaluated?
Pupillary reaction, motor response, verbal response
Eye opening, verbal response, motor response
Reflexes, memory, speech
Sensory, coordination, cognition
A nurse suspects cerebrospinal fluid (CSF) leakage from a client’s ear following head trauma. Which method helps determine if cerebrospinal fluid is present?
Do fingerstick test for blood glucose
Test drainage for glucose
Measure urine output
Test for protein levels
Which is a common oral side effect associated with long-term phenytoin therapy?
Glossitis
Gingival hyperplasia
Dental caries
Oral candidiasis
During a tonic-clonic seizure, the nurse’s first action should be to:
Insert a padded tongue blade
Protect the client from injury
Hold the client down to prevent movement
Offer oxygen via mask immediately
Which of the following actions is appropriate for the nurse to take during a seizure? (Select all that apply.)
Loosen restrictive clothing
Place a tongue blade between the teeth
Note the onset, duration, and type of seizure activity
Provide privacy and protect the client from injury
Hold the client down to prevent movements
The nurse is observing a client having a generalized tonic-clonic seizure. Which assessment data should the nurse document? (Select all that apply.)
Time seizure began and ended
Type and sequence of movements
Blood pressure before seizure only
Bowel or bladder incontinence
Which actions are a part of seizure precaution interventions in the hospital? (Select all that apply.)
Pad side rails
Ensure patent IV access
Restrict fluids
Keep oxygen, airway and suction at bedside
Restrain the client during seizure
Which is a key safety measure for a client at risk for seizures?
Keep the room brightly lit
Place the bed in the lowest position and pad the side rails
Restrain the client to prevent falls
Encourage the client to take showers in a bathtub
Which complication is a client with Parkinson’s disease at high risk for?
Pulmonary embolism
Hyperglycemia
Aspiration pneumonia
Seizures
Which of the following are classic motor signs of Parkinson’s disease? (Select all that apply.)
Bradykinesia
Muscle rigidity
Hyperreflexia
Flat affect (mask like face)
A nurse is caring for a client with Parkinson’s disease who has been prescribed levodopa/carbidopa. Which is an appropriate nursing goal for this medication?
Patient will remain seizure free
Patient will demonstrate improved balance and mobility
Patient will have lower blood pressure
Patient will have better cardiac function
Multiple sclerosis is primarily caused by:
Degeneration of dopamine-producing neurons
Autoimmune demyelination of neurons in the CNS
Depletion of acetylcholine at neuromuscular junctions
Infection of peripheral nerves
A client with a spinal cord injury at T4 suddenly develops severe hypertension, pounding headache, flushed face, and sweating above the level of injury. The nurse suspects autonomic dysreflexia. What is the priority nursing action?
Place the client flat in bed and monitor vital signs
Assess for bladder distention and catheterize if necessary
Restrain the client’s extremities to prevent injury
Administer antihypertensive medication
A client with myasthenia gravis may commonly present with which eye-related symptoms? (Select all that apply.)
Ptosis (drooping eyelids)
Diplopia (double vision)
Nystagmus
Photophobia
In a client with suspected myasthenia gravis, what is a positive Tensilon (endrophonium) test?
Temporary improvement of muscle strength after injection
Muscle weakness becomes worse after injection
Constant tremors are relieved
No change in symptoms
Which of the following often precipitates a myasthenic crisis?
Overmedication with anticholinesterases (cholinergic agent)
Taking OTC anticholinergic medication
Excessive dopamine release
Viral demyelination
A client with myasthenia gravis presents with increased muscle weakness, excessive salivation, sweating, and diarrhea after self-adjusting their medication. The nurse recognizes these findings as most consistent with which condition?
Myasthenic crisis
Cholinergic crisis
Autonomic dysreflexia
Multiple sclerosis exacerbation
