Med Surg Ch 70
- ANS-1.
A nurse is assessing a patient with an acoustic neuroma who has been recently admitted to an
oncology unit. What symptoms is the nurse likely to find during the initial assessment?
A)
Loss of hearing, tinnitus, and vertigo
B)
Loss of vision, change in mental status, and hyperthermia
C)
Loss of hearing, increased sodium retention, and hypertension
D)
Loss of vision, headache, and tachycardia
Ans:
A
Feedback:
An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve most responsible
for hearing and balance. The patient with an acoustic neuroma usually experiences loss of
hearing, tinnitus, and episodes of vertigo and staggering gait. Acoustic neuromas do not cause
loss of vision, increased sodium retention, or tachycardia.
- ANS-10.
A patient, diagnosed with cancer of the lung, has just been told he has metastases to the brain.
What change in health status would the nurse attribute to the patient's metastatic brain disease?
A)
Chronic pain
B)
Respiratory distress
C)
Fixed pupils
D)
Personality changes
Ans:
D
Feedback:
Neurologic signs and symptoms include headache, gait disturbances, visual impairment,
personality changes, altered mentation (memory loss and confusion), focal weakness, paralysis,
,aphasia, and seizures. Pain, respiratory distress, and fixed pupils are not among the more
common neurologic signs and symptoms of metastatic brain disease.
- ANS-11.
A patient has just been diagnosed with Parkinson's disease and the nurse is planning the
patient's subsequent care for the home setting. What nursing diagnosis should the nurse
address when educating the patient's family?
A)
Risk for infection
B)
Impaired spontaneous ventilation
C)
Unilateral neglect
D)
Risk for injury
Ans:
D
Feedback:
Individuals with Parkinson's disease face a significant risk for injury related to the effects of
dyskinesia. Unilateral neglect is not characteristic of the disease, which affects both sides of the
body. Parkinson's disease does not directly constitute a risk for infection or impaired respiration.
- ANS-12.
The nurse is caring for a patient with Huntington disease who has been admitted to the hospital
for treatment of malnutrition. What independent nursing action should be implemented in the
patient's plan of care?
A)
Firmly redirect the patient's head when feeding.
B)
Administer phenothiazines after each meal as ordered.
C)
Encourage the patient to keep his or her feeding area clean.
D)
Apply deep, gentle pressure around the patient's mouth to aid swallowing.
Ans:
D
Feedback:
Nursing interventions for a patient who has inadequate nutritional intake should include the
following: Apply deep gentle pressure around the patient's mouth to assist with swallowing, and
administer phenothiazines prior to the patient's meal as ordered. The nurse should disregard the
, mess of the feeding area and treat the person with dignity. Stiffness and turning away by the
patient during feeding are uncontrollable choreiform movements an
- ANS-13.
A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain
tumor. The patient has just exhibited seizure activity for the first time. What is the nurse's priority
response to this event?
A)
Identify the triggers that precipitated the seizure.
B)
Implement precautions to ensure the patient's safety.
C)
Teach the patient's family about the relationship between brain tumors and seizure activity.
D)
Ensure that the patient is housed in a private room.
Ans:
B
Feedback:
Patients with seizures are carefully monitored and protected from injury. Patient safety is a
priority over health education, even though this is appropriate and necessary. Specific triggers
may or may not be evident; identifying these is not the highest priority. A private room is
preferable, but not absolutely necessary.
- ANS-14.
A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning
the patient's care, the nurse should be aware that the effects of the tumor will primarily depend
on what variable?
A)
Whether the tumor utilizes aerobic or anaerobic respiration
B)
The specific hormones secreted by the tumor
C)
The patient's pre-existing health status
D)
Whether the tumor is primary or the result of metastasis
Ans:
B
Feedback:
Functioning pituitary tumors can produce one or more hormones normally produced by the
anterior pituitary and the effects of the tumor depend largely on the identity of these hormones.
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