NURSING 214 Medical-Surgical Nursing 1_ Test 2 (solution guide) Spring 2022
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Module
NURSING 214 Medical-Surgical Nursing 1 (N214)
Institution
Shenandoah University
NURSING 214 Medical-Surgical Nursing 1
Med-surgical Nursing N214 Test 2 Questions & Answers
Mod 4 Glascow coma scale is an neurological assessment tool nurses use. It has three categories. Name them?
Ans - *eye opening
*verbal response
*motor response
Mod 4 The glascow coma scale provi...
Mod 4 Glascow coma scale is an neurological assessment tool nurses use. It has three
categories. Name them?
Ans - *eye opening
*verbal response
*motor response
Mod 4 The glascow coma scale provides an easy way to describe a patient baseline
mental status and to help detect and interpret changes from baseline findings. To use
the scale test the patients ability to respond to verbal, motor and sensory stimulation
and grade your finding according to the scale. If the patient is alert , follows simple
command and is orientated to person, place and time his score will be?
Ans - 15 points the highest possible score.
Mod 4 A low score in one or more categories may signal an impending neurological
crisis. A total score of 7 or less indicates?
Ans - severe neurological damage
Mod 4 What is decorticate posturing?
Ans - posturing toward the spinal cord indicating neurological damage. This is
associated lesion of the corticospinal tract near the cerebral hemisphere, midbrain
dysfunction. Legs are stiffly extended internally rotated and feet plantar flexed.
Mod 4 What is decerbrate posture?
Ans - Hand posturing away from the body indicating neurological damage. This way
score less on the Glasgow coma scale. associated with a lesion of the diencephalon,
pons or midbrain, usually. Ankles and toes are flexed.
Mod 4 What does PERRLA stand for?
Ans - Pupils equally round and reactive to light and accommodations.
Mod 4 What is consensual response?
Ans - this means when you shine a light in one eye the other eye pupil will constrict too.
This is an appropriate response.
Mod 4 Nurses assess motor strength in all extremities a score of 0 means
Ans - no muscle contraction
Mod 4 A score of 5 equals?
Ans - full range of motion
,Mod 4 Your patient cannot express themselves in speech, writing or signs. The cannot
comprehend spoken or written word. You know this is
Ans - aphasia/resulting from brain disease or trauma.
Mod 4 Sensory aphasia is
Ans - receptive
Loss of ability to comprehend spoken word
auditory lost the ability to understand sounds
visual-lost of the ability to understand printed or written figures (like an address, phone
no.)
Mod 4 What is Broca's aphasia?
Ans - speech is reduced. They can utterance of about four words.Understand speech
relatively well. reading and writing is limited.
Mod 4 What is wrenches aphasia?
Ans - ability to grasp the meaning of the spoken word is impaired. Ability to speak is not
impaired but the flow of words is often not appropriate and broken. Reading and writing
is severely impaired.
Mod 4 Your patient calls you in and just keep saying I want blah blah. You know this is?
Ans - broca's aphasia
Mod 4 You tell your patient to lift up their hands and they just stare at you. You know
this is ? Ans - Wernikes aphasia
Mod 4 Your patient cannot express in writing or making sounds or speaking you know
this is Ans - motor/expressive aphasia
Mod 4 What are some nursing interventions for a patient who is experiencing aphasia?
Ans - *provide for picture recognition (memory)/pictures trigger memories from storage
areas of the brain that are different from those used in speech.
*structure the teach methods according to the patients organization of
information/rationale: the patients organization of information will determine the logical
sequence of learning for him or her.
*Monitor the pt behavior during therapy/rationale:the pt mahout agitated and frustrated
during therapy which signals the need to stop the session.
*encourage the patient to use previous learned skills/rationale: distant memories may
remain in tact and this gives the patient some self control
*Assit the family to understand that assertive behavior may be the result of poor
memory/rationale:aggressive or combative behavior by the patient may signal a threat
to self esteem from memory loss.
*request a neuropsychology consult to identify what areas need work.
Mod 4 Your patient has trouble swelling or chewing food. As a nurse you know this is?
Ans - dysphagia
,Mod 4 The big risk with dysphagia is? Ans - aspiration
Mod 4 Patients with dysphagia often don't get enough food or fluids and this means they
are? Ans - dehydrated
constipated
Mod 4 Your patient has slurred speech you know this is? Ans - dysarthria
Mod 4 Dysarthria patient needs what asap for chance of recovery? Ans - speech
pathologist
Mod 4 Your patient asks you to read a note because they cannot understand written
language this is Ans - alexia problems with written language.
Mod 4 Your patient just can't find the right words to express what they are trying to
communicate. This is? Ans - anomia
Mod 4 Your patient asks you to write a phone no. down for them because they no
longer can. This is? Ans - agraphia
Mod 4 You patient cannot dial the phone you know this is? Ans - apraxia loss of ability
to carry out a purposeful motor activity.
Mod 4 You notice your patient is walking funny gait and has seemed to lose their
balance a lot this is Ans - ataxia-gait disturbance or loss of balance, possible brainstem
or cerebellum danage
Mod 4 Your patient can no longer read or write? Ans - agnosia/general term for loss of
sensory comprehension, may include an inability to write, comprehend reading,material,
or use an object correctly.
Mod 4 What are modifiable risk factors for CVA? Ans - *smoking
*HTN
*illegal drug use
*atherosclerotic disease (high fat diet)
*sedentary lifestyle
*diabetes
*heavy alcohol use
Mod 4 What are non modifiable risk factors of a CVA? Ans - *trauma
*sickle cell anemia
*african American, Hispanic, American Indian
*male
*older age
*atrial fibulation
, *valvular heart disease.
Mod 4 What are most ischemic stroke associated with? Ans - atherosclerosis
Mod 4 What is a TIA? Ans - Transient ischemia attack is a temporary interruption of
blood flow to the brain, that usually clears within 12 to 24 hours. Its usually considered a
warning sign of an impending thrombotic stoke.
Mod 4 What is the percentage of TIA that turns into CVA? Ans - 50-80%
Mod 4 What age makes a big difference in TIA's? Ans - After 50 the incidence of tia
resulting in stroke greatly increases.
Mod 4 What men are the highest risk group? Ans - Black men
Mod 4 What happens is a tia? Ans - patient loses some function: unilateral blindness,
unilateral weakness or numbness, speech deficit or others but the regain full function
quickly.
Mod 4 What is a thrombus? Ans - clot
Mod 4 What is an embolus? Ans - moving clot which can lodge in heart, lungs or brain.
Mod 4 What is another name for TIA's? Ans - mini stroke or silent stroke
Mod 4 What is an ischemic stroke? Ans - blockage of a cerebral artery by a thrombus or
embolus. A stoke is a sudden interruption of circulation in one or more blood vessels to
the brain. During a stroke the brain tissue fails to receive adequate oxygenation
resulting in serious tissue damage or necrosis. Usually associated with development of
atherosclerosis.
Mod 4 What is the biggest factor in a stroke relating to recovery? Ans - the speed at
which circulation is restored determines the patients chance of recovery.
Mod 4 Which stroke is more common ischemic or hemorrhagic? Ans - ischemic
Mod 4 Which stroke is more deadly ischemic or hemorrhage? Ans - hemmorhagic
Intraparenchymal hemorrhage
Intraparenchymal hemorrhage occurs when a blood vessel to the brain ruptures and
bleeds, causing rapidly increasing pressure in the brain.
Subarachnoid hemorrhage
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