RNSG 1538 - REPRODUCTION AND
HUMAN DEVELOPMENT- 2024 EXAM #2
QUESTONS AND ANSWERS
Kernig's sign - Answer-a nurse is assessing a client with meningitis. The nurse places
the client in a supine position and flexes the client's leg at the hip and knee. The nurse
notes resistance when straightening the knee and the client reports pain. The nurse
should document what neurologic sign as positive?
A positive kernig's sign - Answer-is a manifestation of meningeal irritation.
Kernig's sign - Answer-the nurse can elicit this sign by placing the client in a supine
position and flexing the leg at the hip and knee. Pain or resistance when the knee is
straightened suggests meningeal irritation.
Babinski's reflex - Answer-dorsiflexion of the great toe with extension fanning of the
other toes is an abnormal reflex elicited by firmly stroking the lateral aspect of the feet
with a blunt object.
Babinski's reflex - Answer-is an indicator of corticospinal damage.
Brudzinski's sign - Answer-flexion of the hips and knees in response to positive flexion
of the neck that also signals meningeal irritation.
Lichtheim's sign - Answer-is the inability to speak associated with subcortical aphasia.
The decision is whether you want to honor their wishes concerning organ donation. -
Answer-a coordinator from an organ procurement agency is leading a meeting with a
physician, a nurse, and the parent of a client with confirmed brain death. The client's
driver's license indicates that they are an organ donor. After the meeting, the client's
parent states, i just can't make the decision to let him die. Which response by the nurse
is best?
The client can be pronounced dead - Answer-because the client meets the criteria for
brain death.
Although the required position may not be comfortable, it will make the procedure safer
and easier to perform. - Answer-a client preparing to undergo a lumbar puncture states
they don't think they will be able to get comfortable with their knees drawn up to the
abdomen and the chin touching their chest. The client asks if they can lie on their left
side. Which statement is the best response by the nurse?
,The knee-chest position - Answer-is necessary to make the procedure of lumbar
puncture safer and easier to perform.
Conductive hearing loss - Answer-audiometry confirms a client's chronic progressive
hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a
condition that prevents sound transmission. This type of hearing loss is called....
Conductive hearing loss - Answer-results from interference with the conduction of sound
waves from the tympanic membrane to the inner ear. The stapes must move freely for
sound to be transmitted. Bone tissue overgrowth causes the stapes to become fixed or
immobile in the oval window, preventing sound transmission.
Functional hearing loss - Answer-no organic lesion is found
Fluctuating hearing loss - Answer-a form of sensorineural hearing loss that varies over
time.
Sensorineural hearing loss - Answer-affects the inner ear and involves the cochlea and
8th cranial nerve
Absence of reflexes along with flaccid extremities - Answer-a client with quadriplegia is
in spinal shock. What finding should the nurse expect?
Spinal shock occurs - Answer-during the period immediately following a spinal cord
injury
In spinal shock - Answer-all reflexes are absent and the extremities are flaccid.
Jugular vein distention - Answer-a nurse is assessing a client with syndrome of
inappropriate antidiuretic hormone. Which finding requires further action?
JVD - Answer-signals vascular fluid overload
It is a chronic disease in which there is a disturbance in nerve transmission to the
muscle, resulting in fatigue and muscle weakness. - Answer-a client with a new
diagnosis of myasthenia gravis asks, what is happening to me? What would be the most
appropriate response by the nurse?
Myasthenia gravis - Answer-a neuromuscular disorder that progresses very rapidly and
has profound fatigue and muscle weakness
MS - Answer-a debilitating disease involving the myelin sheath
Huntington's chorea - Answer-a chronic disease with a disturbance in nerve
transmission
,Amyotrophic lateral sclerosis - Answer-a progressive, degenerative disease involving
lower motor neurons
Increased intracranial pressure - Answer-the nurse is assessing a client with a head
injury. On admission, the pupils were equal; now the right pupil is fully dilated and
nonreactive, and the left pupil is 4 mm and reacts to light. What would this change in
neurologic status suggest to the nurse?
Ensure that oxygen is flowing at 5 liters per minute by nasal cannula.
Check the client's pulse oximetry reading every 1 hour. - Answer-a client is stabilized in
the emergency department and moved to the neurologic intensive care unit with a
diagnosis of spinal cord injury at level C4-C5. The nurse is working with an experienced
unlicensed assistive personnel. Which items can the nurse delegate to the UAP? Select
all that apply.
You should review this info with your healthcare provider at every admission. - Answer-
a 35 year old client diagnosed with multiple sclerosis three years ago presents the
nurse with an advance directive refusing intubation, mechanical ventilation, and tube
feedings. How should the nurse respond?
Ischemic stroke - Answer-blood supply is interrupted by thrombus, embolus, or stenosis.
Hemorrhagic stroke - Answer-ruptured blood vessel
Stroke - Answer-5th leading cause of death in the US
More common in men
Highest incidence in over 65 age group
The leading cause of serious long term disability in the US
Financial impact can be profound
- CT without contrast because contrast can mask the bleed
Ischemic stroke - Answer-blood flow blocked by blockage or stenosis of a cerebral
artery
Ischemic stroke - Answer-classified as transient, thrombotic, or embolic
Ischemic stroke - Answer-accounts for about 87% of all strokes
TIA - Answer-mini stroke
TIA - Answer-neurological manifestations vary according to location
Brief period of ischemia causing neurological deficits lasting less than 24 hours
- contralateral weakness or numbness of leg, hand, forearm, corner of mouth
- aphasia
- visual disturbances
- may be warning sign for ischemic stroke
, - causes
- inflammatory artery disorders
- sickle cell disease
- atherosclerotic changes in cerebral vessels
- thrombosis
- emboli
Thrombotic stroke - Answer-large vessel occlusion by a thrombus
- commonly caused by atherosclerotic plaque that triggers the clotting sequence with
platelet adherence thus forming a thrombus
- usually only affects 1 region of the brain that was supplied by a single artery
- many times begins with TIA then worsens over 1-3 days resulting in completed stroke
with edematous and necrotic brain tissue
- seen more in older patients and when resting
Embolic stroke - Answer-a piece of thrombus or other matter traveling through small
vessels in the brain becomes lodged in a vessel
Seen more in younger patients and when awake / active
Many come from thrombus in left chambers of the heart
- atrial fibrillation
- bacterial endocarditis
- recent MI
- rheumatic heart disease
- ventricular aneurysm
Sudden onset with immediate deficits
Hemorrhagic stroke - Answer-cerebral blood vessel ruptures
- many times caused by sustained elevate4d BP or aneurysm
Usually occur suddenly and when patient is active
Manifestations depend on location
- vomiting
- headache
- seizures
- hemiplegia
- loss of consciousness
Intracerebral hemorrhage - Answer-bleeding within the brain
Subarachnoid hemorrhage - Answer-bleeding into spaces around the brain
Stroke risk factors - Answer-hypertension
Heart disease (a. Fib, heart failure, valve disease, congenital defects)
DM
Sleep apnea (increases BP and CO2 in blood)
High cholesterol
Smoking
HUMAN DEVELOPMENT- 2024 EXAM #2
QUESTONS AND ANSWERS
Kernig's sign - Answer-a nurse is assessing a client with meningitis. The nurse places
the client in a supine position and flexes the client's leg at the hip and knee. The nurse
notes resistance when straightening the knee and the client reports pain. The nurse
should document what neurologic sign as positive?
A positive kernig's sign - Answer-is a manifestation of meningeal irritation.
Kernig's sign - Answer-the nurse can elicit this sign by placing the client in a supine
position and flexing the leg at the hip and knee. Pain or resistance when the knee is
straightened suggests meningeal irritation.
Babinski's reflex - Answer-dorsiflexion of the great toe with extension fanning of the
other toes is an abnormal reflex elicited by firmly stroking the lateral aspect of the feet
with a blunt object.
Babinski's reflex - Answer-is an indicator of corticospinal damage.
Brudzinski's sign - Answer-flexion of the hips and knees in response to positive flexion
of the neck that also signals meningeal irritation.
Lichtheim's sign - Answer-is the inability to speak associated with subcortical aphasia.
The decision is whether you want to honor their wishes concerning organ donation. -
Answer-a coordinator from an organ procurement agency is leading a meeting with a
physician, a nurse, and the parent of a client with confirmed brain death. The client's
driver's license indicates that they are an organ donor. After the meeting, the client's
parent states, i just can't make the decision to let him die. Which response by the nurse
is best?
The client can be pronounced dead - Answer-because the client meets the criteria for
brain death.
Although the required position may not be comfortable, it will make the procedure safer
and easier to perform. - Answer-a client preparing to undergo a lumbar puncture states
they don't think they will be able to get comfortable with their knees drawn up to the
abdomen and the chin touching their chest. The client asks if they can lie on their left
side. Which statement is the best response by the nurse?
,The knee-chest position - Answer-is necessary to make the procedure of lumbar
puncture safer and easier to perform.
Conductive hearing loss - Answer-audiometry confirms a client's chronic progressive
hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a
condition that prevents sound transmission. This type of hearing loss is called....
Conductive hearing loss - Answer-results from interference with the conduction of sound
waves from the tympanic membrane to the inner ear. The stapes must move freely for
sound to be transmitted. Bone tissue overgrowth causes the stapes to become fixed or
immobile in the oval window, preventing sound transmission.
Functional hearing loss - Answer-no organic lesion is found
Fluctuating hearing loss - Answer-a form of sensorineural hearing loss that varies over
time.
Sensorineural hearing loss - Answer-affects the inner ear and involves the cochlea and
8th cranial nerve
Absence of reflexes along with flaccid extremities - Answer-a client with quadriplegia is
in spinal shock. What finding should the nurse expect?
Spinal shock occurs - Answer-during the period immediately following a spinal cord
injury
In spinal shock - Answer-all reflexes are absent and the extremities are flaccid.
Jugular vein distention - Answer-a nurse is assessing a client with syndrome of
inappropriate antidiuretic hormone. Which finding requires further action?
JVD - Answer-signals vascular fluid overload
It is a chronic disease in which there is a disturbance in nerve transmission to the
muscle, resulting in fatigue and muscle weakness. - Answer-a client with a new
diagnosis of myasthenia gravis asks, what is happening to me? What would be the most
appropriate response by the nurse?
Myasthenia gravis - Answer-a neuromuscular disorder that progresses very rapidly and
has profound fatigue and muscle weakness
MS - Answer-a debilitating disease involving the myelin sheath
Huntington's chorea - Answer-a chronic disease with a disturbance in nerve
transmission
,Amyotrophic lateral sclerosis - Answer-a progressive, degenerative disease involving
lower motor neurons
Increased intracranial pressure - Answer-the nurse is assessing a client with a head
injury. On admission, the pupils were equal; now the right pupil is fully dilated and
nonreactive, and the left pupil is 4 mm and reacts to light. What would this change in
neurologic status suggest to the nurse?
Ensure that oxygen is flowing at 5 liters per minute by nasal cannula.
Check the client's pulse oximetry reading every 1 hour. - Answer-a client is stabilized in
the emergency department and moved to the neurologic intensive care unit with a
diagnosis of spinal cord injury at level C4-C5. The nurse is working with an experienced
unlicensed assistive personnel. Which items can the nurse delegate to the UAP? Select
all that apply.
You should review this info with your healthcare provider at every admission. - Answer-
a 35 year old client diagnosed with multiple sclerosis three years ago presents the
nurse with an advance directive refusing intubation, mechanical ventilation, and tube
feedings. How should the nurse respond?
Ischemic stroke - Answer-blood supply is interrupted by thrombus, embolus, or stenosis.
Hemorrhagic stroke - Answer-ruptured blood vessel
Stroke - Answer-5th leading cause of death in the US
More common in men
Highest incidence in over 65 age group
The leading cause of serious long term disability in the US
Financial impact can be profound
- CT without contrast because contrast can mask the bleed
Ischemic stroke - Answer-blood flow blocked by blockage or stenosis of a cerebral
artery
Ischemic stroke - Answer-classified as transient, thrombotic, or embolic
Ischemic stroke - Answer-accounts for about 87% of all strokes
TIA - Answer-mini stroke
TIA - Answer-neurological manifestations vary according to location
Brief period of ischemia causing neurological deficits lasting less than 24 hours
- contralateral weakness or numbness of leg, hand, forearm, corner of mouth
- aphasia
- visual disturbances
- may be warning sign for ischemic stroke
, - causes
- inflammatory artery disorders
- sickle cell disease
- atherosclerotic changes in cerebral vessels
- thrombosis
- emboli
Thrombotic stroke - Answer-large vessel occlusion by a thrombus
- commonly caused by atherosclerotic plaque that triggers the clotting sequence with
platelet adherence thus forming a thrombus
- usually only affects 1 region of the brain that was supplied by a single artery
- many times begins with TIA then worsens over 1-3 days resulting in completed stroke
with edematous and necrotic brain tissue
- seen more in older patients and when resting
Embolic stroke - Answer-a piece of thrombus or other matter traveling through small
vessels in the brain becomes lodged in a vessel
Seen more in younger patients and when awake / active
Many come from thrombus in left chambers of the heart
- atrial fibrillation
- bacterial endocarditis
- recent MI
- rheumatic heart disease
- ventricular aneurysm
Sudden onset with immediate deficits
Hemorrhagic stroke - Answer-cerebral blood vessel ruptures
- many times caused by sustained elevate4d BP or aneurysm
Usually occur suddenly and when patient is active
Manifestations depend on location
- vomiting
- headache
- seizures
- hemiplegia
- loss of consciousness
Intracerebral hemorrhage - Answer-bleeding within the brain
Subarachnoid hemorrhage - Answer-bleeding into spaces around the brain
Stroke risk factors - Answer-hypertension
Heart disease (a. Fib, heart failure, valve disease, congenital defects)
DM
Sleep apnea (increases BP and CO2 in blood)
High cholesterol
Smoking
