Brooke Cybel Tanate Neurosensory test questionnaire Knowledge 3

1. Which of the following terms related to aphasia refers to the failure to recognize familiar objects perceived by the senses? a) b) c) d) Agnosia Agraphia Apraxia Perseveration

2. The nurse formulates a nursing diagnosis of Risk for imbalanced body temperature for a client who suffers a cerebrovascular accident (CVA) after surgery. When developing expected outcomes, the nurse incorporates assessment of the client's temperature to detect abnormalities. The thermoregulatory centers are located in which part of the brain? a. Pons b. Cerebellum c. Temporal lobe d. Hypothalamus
B 3 Myasthenia gravis is due to ____ receptors being blocked and destroyed by antibodies.

A. Epinephrine B. Nicotinic C. Acetylcholine D. Transient Comprehension 3 4. Which of the following statements reflect nursing management of the patient with expressive aphasia? a) Encourage the patient to repeat sounds of the alphabet. b) Speak clearly and in simple sentences; use gestures or pictures when able. c) Speak slowly and clearly to assist the patient in forming the sounds. d) Frequently reorient the patient to time, place, and situation.

5. Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? a) Widened pulse pressure b) Increased pulse c) Decreased respirations d) Decreased body temperature

6. Which of the following terms refers to muscular hypertonicity with increased resistance to stretch? a) Spasticity b) Akathesia c) Ataxia d) Myclonus Application 7 6. A client is admitted to the emergency department with a suspected overdose of an unknown drug. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? a. Prepare to assist with ventilation. b. Monitor the client's heart rhythm. c. Prepare for gastric lavage. d. Obtain urine for drug screening. 7.A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment? a. Determine the level at which the patient has intact sensation. b. Assess the level at which the patient has retained mobility. c. Check blood pressure and pulse for signs of spinal shock. d. Monitor respiratory effort and oxygen saturation level. 8.You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursing assistant when providing nursing care for a patient with SCI? a. Assess patient s respiratory status every 4 hours. b. Take patient s vital signs and record every 4 hours. c. Monitor nutritional status including calorie counts. d. Have patient turn, cough, and deep breathe every 3 hours. 9.The patient with multiple sclerosis tells the nursing assistant that after physical therapy she is too tired to take a bath. What is your priority nursing diagnosis at this time? a. Fatigue related to disease state b. Activity Intolerance due to generalized weakness c. Impaired Physical Mobility related to neuromuscular impairment d. Self-care Deficit related to fatigue and neuromuscular weakness 10 A patient with Parkinson s disease has a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which action must you intervene? a. The NA assists the patient to ambulate to the bathroom and back to bed. b. The NA reminds the patient not to look at his feet when he is walking. c. The NA performs the patient s complete bath and oral care. d. The NA sets up the patient s tray and encourages patient to feed himself.

Analysis7 11. A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a. a positive edrophonium (Tensilon) test. b. Kernig's sign. c. a positive sweat chloride test. d. Brudzinski's sign. 12. Nursing Neurological Exam about a 76-year-old woman who dies at home from sudden cardiac arrest after the onset of ventricular fibrillation. The family consents to an autopsy that reveals several small infarcts throughout the basal ganglia. Assuming that the defects arise from a single vessel within the central nervous system, pathology from which artery would be most consistent with this finding? (A) Anterior cerebral artery (B) Anterior communicating artery (C) Lateral striate artery (D) Posterior cerebral artery 13. A 63-year-old homeless woman is brought to the emergency department by the police, who noted her to be disoriented and confused. On questioning, the patient appears to be having problem with her short-term memory, frequently forgetting what question she had been asked. She provides plausible details of the events prior to her coming to the hospital, but the police report to be untrue. On physical examination she is emaciated and has nystagmus and an unsteady gait. Examination of emergency department records reveals that she has presented multiple times in the past for alcohol withdrawal. The lesion accounting for the patient s symptoms is located in which part of the brain? (A) Basal ganglia (B) Broca s area (C) Cerebellar vermis (D) Mamillary bodies A 14. When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient s posturing as a) b) c) d) decerebrate. normal. flaccid. decorticate.

Evaluation3 15.A patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer s disease. Her husband tells you that he rarely gets a good night s sleep because he needs to be sure she does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient? a. Decreased Cardiac Output related to poor myocardial contractility b. Caregiver Role Strain related to continuous need for providing care c. Ineffective Therapeutic Regimen Management related to poor patient memory d. Risk for Falls related to patient wandering behavior during the night 16. The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient indicates that additional teaching is necessary? a. b. c. d. I will avoid exercise because the pain gets worse. I will use heat or ice to help control the pain. I will not wear high-heeled shoes at home or work. I will purchase a firm mattress to replace my old one.

17. Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to the neurologic unit? a. A 28-year-old newly admitted patient with spinal cord injury b. A 67-year-old patient with stroke 3 days ago and left-sided weakness c. An 85-year-old dementia patient to be transferred to long-term care today d. A 54-year-old patient with Parkinson s who needs assistance with bathing Synthesis 2 18.Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? a. A 34-year-old patient newly diagnosed with multiple sclerosis (MS) b. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS) c. A 56-year-old patient with Guillain-Barre syndrome (GBS) in respiratory distress d. A 25-year-old patient admitted with CA level spinal cord injury (SCI) 19. You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately? a. The student enters the room without putting on a mask and gown. b. The student instructs the family that visits are restricted to 10 minutes. c. The student gives the patient a warm blanket when he says he feels cold. d. The student checks the patient s pupil response to light every 30 minutes.

1.a 2d 3b 4 a) Encourage the patient to repeat sounds of the alphabet. Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet. b) Speak clearly and in simple sentences; use gestures or pictures when able. Nursing management of the patient with global aphasia includes speaking clearly and in simple sentences and using gestures or pictures when able. c) Speak slowly and clearly to assist the patient in forming the sounds. Nursing management of the patient with receptive aphasia includes speaking slowing and clearly to assist the patient in forming the sounds. d) Frequently reorient the patient to time, place, and situation. Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation.
5) A- Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine sample for drug screening. 6. a) Widened pulse pressure Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature. b) Increased pulse Bradycardia, slowing of the pulse, is an indication of increasing ICP in the head-injured patient. c) Decreased respirations Rapid respiration is an indication of increasing ICP in the head-injured patient. d) Decreased body temperature A rapid rise in body temperature is regarded as unfavorable because hyperthermia may indicate brain stem damage, a poor prognostic sign. 7

a) Spasticity Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. b) Akathesia Akathesia refers to a restless, urgent need to move around and agitation. c) Ataxia Ataxia refers to impaired ability to coordinate movement. d) Myclonus Myoclonus refers to spasm of a single muscle or group of muscles.