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NUR 169 Exam 1 Review Flashcards | StudBud
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NUR 169 Exam 1 Review
NUR 169 Exam 1 Review
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1
A left-handed pt with L-sided hemiplegia has trouble feeding himself. What intervention is most appropriate?
Provide a wide-variety of food choices
Teach him the "chin-tuck" technique when swallowing
Provide oral care before and after meals
Assist him to eat with his right hand
2
When caring for a patient with MG, what would be the RNs first priority
Maintaining respiratory function
Maintaining mobility
Adequate nutrition
Maintaining verbal communication
3
A nurse is taking a pt on a stretcher to radiology. The pt starts having a tonic-clonic seizure. What does the RN do?
Avoid touching the pt to reduce stimulation
Restrain the pt arms and legs for safety
Note time, observe behavior, and record the details of seizure/post ictal
Insert an oral airway
4
What action would the nurse plan to take for a pt with MS and urinary retention due to flaccid bladder?
Encourage them to decrease their fluid intake
Assist the patient to the commode every 2 hours
Suggest the use of adult incontinence briefs
Teach them how to self-catheterize
5
A pt with ALS is hospitalized with pneumonia. Which action would the nurse include in the plan of care?
Give muscle relaxants to reduce the spasms
Observe for signs of agitation and paranoia
Use simple words and phrases to explain procedures
Assist with range of motion and repositioning
6
During the
rehab
phase of stroke care, what is an important intervention for a pt who has unilateral neglect?
Alternate patching R and L eyes to reverse the neglect
Place all needed objects on the unaffected side so the pt can find them
Avoid positioning the patient on the affected side
Teach the pt to care conciously for the affected side
7
A pt reports numbness/tingling on the right arm before having a seizure. Which type of seizure does the nurse suspect?
Focal
Myoclonic
Absence
Atonic
8
What is the main goal of treatment for patients with neurodegenerative disorders?
Cure the disease with experimental medications
Prevent the development of future chronic diseases
Maximize neurological function for as long as possible
Meet the patient's personal care needs
9
A nurse would recommend that a pt with MS save physically demanding tasks for the end of the day to conserve energy.
True
False
10
After a generalized tonic-clonic seizure, the pt is tired/sleepy in the post-ictal phase. What action will the RN take?
Allow the patient to rest as long as he feels sleepy
Suction the patient before allowing him to sleep
Check the pt neuro status every 5 minutes for an hour
Stimulate the pt to increase his awareness
11
A pt arrives to the ED with L-sided hemiparesis. Which action would the RN take FIRST?
Check the airway and respiratory effort
Assess the pt's Glasgow Coma Scale
Check the BP and vital signs
Send the patient to CT
12
Which stroke risk factor for a 50 year old male is most important for the RN to address?
He works at a desk and relaxes by reading
The patient has uncontrolled HTN because of medications non-compliance
He drinks one glass of wine every night with dinner
He is 20 pounds overweight
13
A patient had a stroke with right sided face droop, and right leg/arm paralysis. What other finding would you expect?
Hyperactive left-sided reflexes
Difficulty comprehending instructions
left-sided neglect
Impulsive behavior
14
Which info is MOST important to report to the Dr about a pt who had a subarachnoid hemorrhage?
Pt reports a "stiff neck"
Pt continues to report severe headache
CSF has RBCs in it
The pt BP is 90/45
15
The RN sees a pt in the hallway fall to the floor and have a tonic-clonic seizure. What is the RN's FIRST action?
Give the patient's scheduled antiseizure medication
Call the healthcare provider
Ensure pt safety by checking for items/clothing that can cause pt injury
Stand in hallway out of reach of the patient and time the seizure
16
What intervention would be included for a patient with R-sided homonymous hemianopsia after a stroke?
Apply an eye patch to the right eye
Teach the patient that the left eye deficit will resolve
Approach the patient on the right side
Place needed objects on pt's left side
17
A pt with Parkinson has bradykinesia. Which action would the nurse include when planning care?
Suggest the pt use the arms of the chair to push on to assist to stand
Instruct the pt to find activities that can be done while lying or sitting
Tell pt to keep feet in contact with the floor and "shuffle" when walking
Have the pt take small steps toe-to-toe when walking
18
A pt is going to eat for the first time after a stroke and has passed a swallow test. What is the RN's next action?
Assist the patient upright into a chair
Assess the patient's appetite
Offer the patient a sip of juice
Order a pureed diet
19
A pt with L-sided brain stroke suddenly bursts into tears. How will the nurse explain this to the family?
Teach the family that emotional outbursts are common after stroke
Let the patient be alone until they can compose themselves
In a calm voice, tell the pt to please stop crying
Explain to the family that depression is common after a stroke
20
A elderly pt is seen w/new onset stooped posture, tremor, shuffling gait. What topic would the nurse expect to discuss?
Dopaminergic drugs
MRI testing
EEG testing
Oral corticosteroids
21
Which of the following neurodegenerative disorders are autoimmune related-diseases?
ALS
Focal Seizures
Myasthenia Gravis
Multiple Sclerosis
22
Which concern woule dht nurse anticipate for a patient who had a right hemisphere stroke?
Impulsivity and denial of deficits
Speech and language deficits
Depression about disability
Right-sided hemiplegia
23
Whan providing care for a pt with ALS, what would the nurse recognize as one of th emost distressing problems for the pt
Retention of cognitive function with total degeneration of motor function
Uncontrollable tonic-clonic muscle movements
Knowledge that there is a 50% chance that their children will get ALS
Painful spasticity of the face and extremities
24
Multiple sclerosis is characterized by demyelination of the nerve fibers in the brain and spinal cord.
False
True
25
A pt with history of TIA is taking ASA 160mg. The pt states "I'm not in pain--I don't need ASA today". What do you do?
Tell the pt that the ASA is given to prevent pain
Explain that the ASA is given to help prevent stroke after TIA
Call the pharmacy to have the order discontinued
Document that the pt refused the ASA
26
A pt had a stroke 24 hours ago and has expressive aphasia. Which intervention is most appropriate to help to communicate
Have the pt practice mouth and tongue exercises in the mirror
Ask "yes" or "no" questions
Give them a list of key word to practice saying
Answer for the pt so they don't get embarrassed
27
The pt is recieving IV chemo. Which action would the nurse take?
Give the medication through the smallest IV possible
Give the chemo agent rapidly over a short period of time
Stop the IV is swelling or pain is noted at the IV site
Slow down the infusion if pain and swelling is noted at the IV site
28
A pt is admitted for MG crisis. What is the RN's priority concern?
Providing communication board
Supporting pt respiratory effort and preventing aspiration
Providing ROM exercises to prevent contractions
Providing adequate fluids to account for fluid loss (sweating and diarrhea)
29
A hemorrhagic stroke is suspected if a patient reports a severe headache followed by stroke like symptoms.
True
False
30
A patient with L-sided weakness arrives to the ED--which diagnostic test will be done FIRST?
CT scan
MRI
CBC
Chest X-ray
31
A stroke pt has increasing weakness and decreasing LOC. Which potential problem is the highest priority to address
Musculoskeletal weakness
Risk for impaired skin integrity
Risk for aspiration
Sensory deficit
32
What instructions would the nurse give the pt receiving radiation to the neck who has painful oral lesions?
Use cotton-tipped swabs in hydrogen peroxide to clean teeth
Brush teeth after meals with a stiff toothbrush to clean away food debris
Rinse mouth before/after meals and at bedtime with a saline solution
Gargle and rinse mouth with an antiseptic mouthwash
33
A person has been taking phenytoin for 10 years. Which action would the RN take to monitor for adverse reaction?
Inspect oral mucosa
Auscultate bowel sounds
Check pupillary reaction to light
Listen to lung sounds
34
Which topic would the nurse discuss with a patient who had a TIA who's symptoms resolved?
Heparin infusion
Oral low-dose ASA
tPA
Cerebral aneurysm clipping
35
A tech is caring for a pt w/radioactive implants Which action would be cause for the RN to intervene?
The tech gives the pt an alcohol-containing mouthwash for oral care
The tech flushes the pt toilet once after emptying the bedpan
The tech stands close to the beside and talks with the pt for 30 minutes
The tech puts the pt linens in a bag in the hallway
36
Which action is MOST effective to improve oral intake in a pt receiving chemo with painful mouth lesions?
Assist the patient to choose favorite foods to eat
Apply perscribed anesthetic gel to oral lesions before meals
Teach the patient about making good nutritional choices
Offer the patient small snacks between meals
37
IV edrophonium may be given to determine if a pt is in MG or cholinergic crisis
False
True
38
A pt with cancer reports severe vomiting after each chemotherapy treatment. Which action should the nurse take?
Give them dry crackers and ginger ale during chemo treatments
Have the pt eat extra large meals whenever they aren't vomiting
Administer prescribed antiemetics 1 hr before each chemo treatment
Give them a glass of OJ during chemo treatments
39
What info about clopidogrel will the RN provide during patient teaching?
Monitor BP daily
Call your health care provider if you have tarry stools
This medication will dissolve the plaque in your carotid arteries
This medication will dissolve the clots in your cerebral arteries
40
One of the first signs of multiple sclerosis is tremors during activity
True
False
