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Adult Health Exam # 3/319 Questions and answers
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Adult Health Exam # 3/319Questions and answers
During a patient's neurologic assessment, the
nurse finds that he is arousable after light
touch combined with a loud voice. How does
the nurse document this patient's level of
consciousness?
A. Stuporous
B. Lethargic
C. Comatose
D. Drowsy - -B. Lethargic
-In older adults, a decrease in _____________
____________ is a key early sign of an
infectious process. - -mental status
-Changes in _____________ are the earliest
signs of changes in neurologic status - -cognition
-A decrease of ____ or more points in the
Glasgow Coma Scale total is clinically
significant and should be reported to the
health care provider immediately.
A. 1
B. 2
C. 3
D. 4 - -B. 2
-What pre-procedure preparations should the
nurse complete in a patient undergoing a
lumbar puncture? - -1. Obtain informed consent
2. Explain the procedure
3. Positioning required
-A patient is admitted to the critical care unit
with possible Guillain-Barré syndrome. Which
symptom of neurologic impairment will require
priority nursing interventions? Select all that
apply.
A. New adventitious breath sounds
B. A respiratory rate of 12
C. Rapid, shallow breathing pattern
,D. A peripheral oxygen saturation (Spo2) of 90%
E. New-onset nausea following a position change - -A. New adventitious
breath sounds
C. Rapid, shallow breathing pattern
D. A peripheral oxygen saturation (Spo2) of 90%
-The nurse is about to administer a contrast medium to the client
undergoing diagnostic testing. Which question does the nurse first ask the
client?
A. "Are you taking ibuprofen daily?"
B. "Are you in pain?"
C. "Are you wearing any metal?"
D. "Do you know what this test is for?" - -A. "Are you taking ibuprofen daily?"
-A client has just returned from cerebral angiography. Which symptom does
the client display that causes the nurse to act immediately?
A. Bleeding
B. Increased temperature
C. Severe headache
D. Urge to void - -A. Bleeding
-A client has received contrast medium. Which teaching does the nurse
provide to avoid any neurologic health problems after the procedure?
A. "Practice memory drills this afternoon."
B. "Drink at least 1000 to 1500 mL of water today."
C. "Avoid sunlight."
D. "Rest in bed for 24 hours." - -B. "Drink at least 1000 to 1500 mL of water
today."
-A client has undergone single-photon emission computed tomography
(SPECT). Which instruction does the nurse give the client?
A. "Continue to use the ice pack."
B. "Call me if you have any itching."
C. "Keep the head of the bed flat."
D. "Return to your usual activity." - -D. "Return to your usual activity."
-Which client diagnosed with neurologic injury is typically at highest risk for
depression?
A. Young man with a spinal cord injury
B. Older man with a spinal cord injury
C. Older man with a mild stroke
,D. Young woman with a mild stroke - -A. Young man with a spinal cord injury
-Which cranial nerve allows a person to feel a light breeze on the face?
A. I (olfactory)
B. III (oculomotor)
C. V (trigeminal)
D. VII (facial) - -C. V (trigeminal)
-The nurse is performing a neurologic assessment on an 81-year-old client.
Which physiologic change does the nurse expect to find because of the
client's age?
A. Decreased coordination
B. Increased sleeping during the night
C. Increased touch sensation
D. Stability in pain perception - -A. Decreased coordination
-The nurse prepares to assess a client with diabetes mellitus for sensory
loss. Which equipment does the nurse use to perform this assessment?
A. Glucometer
B. Hammer
C. Nothing; the client is asked to walk
D. Cotton-tipped applicator - -D. Cotton-tipped applicator
-The nurse is performing a rapid neurologic assessment on a trauma client.
Which assessment finding is normal?
A. Decerebrate posturing
B. Increased lethargy
C. Minimal response to stimulation
D. Constriction of pupils - -D. Constriction of pupils
-Which client does the neurologic unit charge nurse assign to a registered
nurse who has floated from the labor/delivery unit for the shift?
A. Older adult client who was just admitted with a stroke and needs an
admission assessment
B. Young adult client who has had a lumbar puncture and reports, "Light
hurts my eyes."
C. Adult client who has just returned from having a cerebral arteriogram and
needs vital sign checks every 15 minutes
D. Middle-aged client who has a possible brain tumor and has questions
about the scheduled magnetic resonance imaging - -C. Adult client who has
, just returned from having a cerebral arteriogram and needs vital sign checks
every 15 minutes
-Which task does the nurse plan to delegate to the nursing assistant caring
for a group of clients in the neurosurgical unit?
A. Prepare a client who is going to radiology for a cerebral arteriogram
B. Attend to the care needs of a client who has had a transcranial Doppler
study
C. Assist the health care provider in performing a lumbar puncture on a
confused client
D. Educate a client about what to expect during an electroencephalogram
(EEG) - -B. Attend to the care needs of a client who has had a transcranial
Doppler study
-The nurse has just received change-of-shift report about a group of clients
on the neurosurgical unit. Which client does the nurse attend to first?
A. Young adult client involved in a motor vehicle crash (MVC) who is yelling
obscenities at the nursing staff
B. Adult postoperative left craniotomy client whose hand grips are weaker on
the right
C. Middle-aged adult client who had a cerebral aneurysm clipping and is
increasingly stuporous
D. Older adult client who had a carotid endarterectomy and is unable to state
the day of the week - -C. Middle-aged adult client who had a cerebral
aneurysm clipping and is increasingly stuporous
-The nurse has just received report on a group of clients on the
neurosurgical unit. Which client is the nurse's first priority?
A. Young adult whose Glasgow Coma Scale (GCS) score has changed from 15
to 10
B. Adult whose deep tendon reflexes have become hyperactive
C. Middle-aged adult who displays plantar flexion when the bottom of the
foot is stroked
D. Older adult who consistently demonstrates decortication when stimulated
- -A. Young adult whose Glasgow Coma Scale (GCS) score has changed from
15 to 10
-The nurse has just received report on a group of clients. Which client does
the nurse assess first?
A. Young adult who was in a car accident and has a Glasgow Coma Scale
score of 13
B. Adult who had a cerebral arteriogram and has a cool, pale right leg
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