EXAM 3 PRACTICE QUESTIONS

change in level of consciousness (LOC)

When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is

The patient is more difficult to arouse

When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?

increased systolic BP, decreased pulse, decreased respirations

The nurse recognizes the presence of Cushing's triad in the patient with

Turn the client to the side and allow the client to sleep.

The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?

Tell the UAP to stop trying to insert anything in the mouth.

The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take?

Administer an anticonvulsant medication by intravenous push

The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate?

It lasts less than 24 hrs, blood flow is temporarily blocked to the brain, a predictor of impending stroke

A nurse is caring for a client who came to the clinic after experiencing right arm weakness for a few hours in the morning. The provider tells the client that they experienced a transient ischemic attack (TIA). After the provider leaves the room, the client asks, "What exactly is TIA?" Which of the following should the nurse include in the response?

ischemic stroke

A nurse is caring for a client admitted to ICU for slurred speech, right sided weakness, and facial droop. The prescription includes seizure precautions & tissue plasmogen activator (tPA). Which of the following types of neurological impairment is this client most likely experiencing?

diarrhea, constipation, and sexual dysfunction

A client arrives to the clinic reporting excessive sweating. The nurse reviews the clients medical record & notes a diagnosis of (PAD) peripheral artery disease, resulting in autonomic nerve damage. Which of the following findings should the nurse expect during the assessment?

"I understand that my partner may have difficulty w/ attention & memory for up to 4 weeks"

A nurse is discussing the discharge plan for a client with mild concussion. Which of the following statements by the clients partner indicates an understanding of clients recuperation?

history of atrial fibrillation

A client who was brought to the ER by a friend is reporting right arm weakness & slurred speech, which lasted about 2 hours. Which of the following pieces of medical history information should the nurse expect to receive from the client?

There is a major decrease in dopamine-producing nerve cells of the substantia nigra.

A nurse is caring for a client with a new diagnosis of Parkinson’s Disease. The nurse notices the client has bilateral hand tremors and balance problems when walking to the bathroom. Which of the following pathological process are the basis of the clients clinical manifestations?

Leg cramps, foot drop, paresthesia, numbness

A nurse is assessing a client who has lumbar spinal stenosis. Which of the following findings should the nurse anticipate?