Kaplan Neurology Test A

Kaplan Neurology Test A The nurse identifies which of the following manifestations is MOST characteristic of myasthenia gravis? - ANS - Tiredness with slight exertion Rationale: because of acetylcholine deficiency, tr ...

Kaplan Neurology Test A The nurse identifies which of the following manifestations is MOST characteristic of myasthenia gravis? - ANS - Tiredness with slight exertion Rationale: because of acetylcholine deficiency, transmission of nerve impulses is limited; makes it difficult to stimulate or initiate movement The nurse cares for a patient suspected in having a seizure disorder. The patient tells the nurse, "I smelled oranges today and there wasn't one on my tray." Which of the following responses by the nurse is BEST? - ANS - "Have you experienced this sensation before?" Rationale: nurse should suspect that the patient is describing an aura The nurse cares for a client admitted to the medical/surgical unit diagnosed with a stroke. The nurse plans care to prevent the client from experiencing sensory overload. The nurse determines that which plan is most effective? - ANS - The nurse obtains vital signs and assists the patient with am care in one visit. Rationale: one visit will prevent patient from becoming fatigued. Schedule time for rest and quiet. The nurse instructs the family of a patient diagnosed with Parkinson's disease. Which of the following statements by the family reflects a need for further education? - ANS - "We will buy lots of soup for dad." Rationale: thin liquids are difficult to swallow. Sit in an upright position and encourage thick liquids The nurse plans care for an older adult client recently admitted for acute pulmonary edema. Which is the BEST intervention for the nurse to include in the client's plan of care to prevent sensory deprivation? - ANS - Assess support system from the family Rationale: encourage visitors to decrease isolation The patient diagnosed with Parkinson's disease has tremors of both upper arms. The nurse observes that the tremors disappear as the patient unbuttons his shirt. Which of the following statements indicates the most accurate understanding of the tremors? - ANS - Tremors decrease in severity when attention is diverted by activity Rationale: patients usually experience tremors at rest, they go away when focus is on an activity The nurse understands that which of the following cranial nerves is affected in tic douloureux? - ANS - Trigeminal Rationale: affects the jaw, face, neck (trigeminal neuralgia) Which clinical manifestations should the nurse anticipate when caring for a client with a history of multiple sclerosis? - ANS - Urinary retention—innervation of bladder and urinary tract Hyperreflexia of the extremities— tremors, muscle weakness, spasticity, paresthesia Ataxia— impaired coordination Decreased concentration— frontal/parietal lobe involvement lead to some cognitive changes The nurse instructs a client diagnosed with Bell's palsy. It is MOST important for the nurse to make which statement about nighttime care? - ANS - "Apply an eye shield over the affected eye." Rationale: corneal abrasion can cause blindness; this can occur because pt is unable to close eye The nurse finds a client diagnosed with Ménière's disease leaning over the sink in the room and clutching it with both hands. After determining the client is having an acute attack, which action does the nurse take FIRST? - ANS - Helps the client back to bed and places a pillow on either side of the client's head. Rationale: vertigo can cause falls, lying down will prevent inherit and pillows will prevent movement The nurse notes a newly admitted patient diagnosed with a head injury has a clear nasal drainage. Which of the following actions should the nurse take FIRST? - ANS - Check nasal drainage for glucose Rationale: CSF tests positive for glucose While the nurse ambulated the client to the bathroom, the client begins to to have a seizure. Which of the following actions should the nurse take FIRST? - ANS - Ease the patient to the floor The nurse in the emergency department admits patients from a multi car accident. Which of the following patients should the nurse attend to FIRST? - ANS - A patient with clear fluid draining from the right ear The nurse cares for a patient scheduled for an electroencephalogram (EEG). To prepare the patient for the test, it is MOST important for the nurse to state which of the following? - ANS - "The procedure is not painful but you must lie still." The nurse cares for a patient admitted to the emergency room following an automobile accident. The patient complains of dizziness, and the physician suspects a head injury. The nurse should intervene if which of the following is observed? - ANS - The patient is leaning forward with his head over his knees Rationale: PT neck should be stabilized prior to x-ray The nurse cares for an elderly client admitted for chest pain. The client says to the nurse, "I know my children visited me today, but they deny it. What's going on, I'm so mixed up." The nurse suspects. Such distortions in thinking are due to sensory alterations. Which of these actions by the nurse is BEST? - ANS - Allow the client to discuss the "Mixed-up feelings" Rationale: could be sensory deprivation, talking about it will relieve his anxiety A client is diagnosed with tonic-clonic seizures. The nurse tries to identify the client's aura. Which statement accurately describes an aura? - ANS - Unusual sensations prior to the seizure. A patient is admitted to the hospital with symptoms of myasthenia gravis. When caring for this patient, the nurse should give priority to which of the following nursing goals? - ANS - Maintain respiratory function Which of the following nursing goals is MOST realistic and appropriate in planning care for a patient with Parkinson's disease? - ANS - Maintain optimal fun action within the patient's limitations The nurse identifies a nursing diagnosis of altered nutrition related to inability to fees self for a client diagnosed with right-rides hemiplegia as a result of a cerebrovascular accident. Which intervention is BEST to improve the client's nutrition? - ANS - Provide a puréed diet Rationale: they will have difficulty swallowing The nurse instructs a client about an electroencephalogram (EEG). The nurse informs the client which of the following foods should be omitted from the client's diet before the test? - ANS - Hot chocolate Rationale: it contains caffeine The nurse cares for a patient diagnosed with a closed head injury and increased intracranial pressure. Which of the following actions by the nurse is BEST? - ANS - Instruct patient to cough and deep breathe every two hours Rationale: prevents Valsalva maneuver The nurse cares for a client diagnosed with Ménière's disease. The nurse expects the client to exhibit which symptoms? - ANS - Vertigo, hearing loss, tinnitus Rationale: it is an inner ear disorder characterized by this triad of symptoms The nurse in the outpatient clinic cares for a client diagnosed with Bell's Palsy. Which actions should the nurse take first? - ANS - Assess the client's pain experience The nurse cares for a client diagnosed with a spinal cord injury at the level of T-3. The client reports a pounding headache and nasal congestion. The nurse notes the client has profuse sweating from the forehead and piloerection. Which action does the nurse take FIRST? - ANS - Checks the Foley catheter and tubing for kinks Rationale: if no foley is present, check for bladder distention and catheterize immediately. A client is diagnosed with a possible stroke. The client has a history of hypertension that is not managed well. The client takes antihypertensive medication and hormone replacement therapy. The client's only activity is managing the home, and the client appears overweight. The nurse identifies which client risk factor as MOST important for development of a stroke? - ANS - Hypertension A client has a diagnosis of meningitis. A nurse assesses the client. The nurse notes that when the client flexes the head, the client also flexes the hip and knee. Which action(s) by the nurse is BEST? - ANS - Immediately report this finding to the health care provider Rationale: Brudzinski sign is an indication of meningeal involvement The nurse cares for a client with a Glasgow come scale of 7. The nurse identifies it is important to give eye care to this patient for which reason? - ANS - To prevent corneal irritation The nurse in the outpatient clinic assesses a client diagnosed with trigeminal neuralgia. The nurse should intervene if the client makes which of the following statements? - ANS - "I drink coffee with breakfast and after dinner." Rationale: hot foods can trigger a pain episode. A client is diagnosed with typical absence seizures. It is MOST important for the nurse to take which action? - ANS - Monitor the client for brief interruptions of consciousness