1. The family understands how to help the client with homonymous hemianopsia by not placing objects in their impaired field of vision and having them turn their head to scan their lost visual field.
2. For a child with PKU, scrambled eggs would be an acceptable food since it does not contain phenylalanine which can damage the central nervous system.
3. When taking a history from a patient suspected of having multiple sclerosis, the most important question for a nurse to ask is about vision problems, as demyelination can affect vision.
1. The family understands how to help the client with homonymous hemianopsia by not placing objects in their impaired field of vision and having them turn their head to scan their lost visual field.
2. For a child with PKU, scrambled eggs would be an acceptable food since it does not contain phenylalanine which can damage the central nervous system.
3. When taking a history from a patient suspected of having multiple sclerosis, the most important question for a nurse to ask is about vision problems, as demyelination can affect vision.
1. The family understands how to help the client with homonymous hemianopsia by not placing objects in their impaired field of vision and having them turn their head to scan their lost visual field.
2. For a child with PKU, scrambled eggs would be an acceptable food since it does not contain phenylalanine which can damage the central nervous system.
3. When taking a history from a patient suspected of having multiple sclerosis, the most important question for a nurse to ask is about vision problems, as demyelination can affect vision.
1. The family understands how to help the client with homonymous hemianopsia by not placing objects in their impaired field of vision and having them turn their head to scan their lost visual field.
2. For a child with PKU, scrambled eggs would be an acceptable food since it does not contain phenylalanine which can damage the central nervous system.
3. When taking a history from a patient suspected of having multiple sclerosis, the most important question for a nurse to ask is about vision problems, as demyelination can affect vision.
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SUPPLEMENTAL REVIEW
1. The nurse has instructed the family of a client with Cerebrovascular Accident who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to us if they stated to:
a. Place objects in the client’s impaired field of vision
b. Approach the client from the impaired field of vision c. Remind the client to turn head to scan the lost visual field d. Discourage the client from wearing eyeglasses
2. A nurse instructs the mother of a three year old child who has PKU about acceptable foods to include in the child’s diet. Which of the following foods, if selected by the mother indicates a correct understanding of the teaching?
a. Chocolate milkshake b. Scrambled eggs c. Peanut butter sandwich d. Animal shaped crackers
RATIONALE CAN DAMAGE THE CNS (PHENYLKETONURIA IS ALSO A GENETIC DISORDER) “I would subject my child for genetic counseling.” TEST: GUTHRIE CAPILLARY TEST ( > 8MG/DL = indicates positive for PKU)
3. Which of the following questions would be the most important for a nurse to ask when taking a history from a patient who is suspected of having Multiple Sclerosis?
a. Are you easily distracted?
b. Is your vision blurred? c. Has your appetite decreased? d. Do you have ringing in your ears?
RATIONALE MULTIPLE SCLEROSIS: Demyelination can affect how the brain can process DEMYELINATION of the myelin sheath sensory, integration and motor. - Sensory has to be string enough to integrate and create a motor response. - myelin sheath breaks down = low nerve impulse TRIAD SYMPTOMS (vision, speech, motor) : Nystagmus, Motor incoordination, Scanning speech SPASTICITY = Dantrium or Baclofen PARESTHESIA = Carbamazepine or Tegetrol URINARY RETENTION = Bethanecol CEREBELLAR ATAXIA: sudden, uncoordinated muscle movement due to disease or injury to the cerebellum (DRUG OF CHOICE: Propanolol) Ataxia (Cerebral ataxia): Motor incoordination problem Multiple Sclerosis Cause: VIRAL = virus attacks the CNS = motor coordination problem
4. Which of the following findings would a nurse expect to observe when assessing a patient who has Myasthenia Gravis?
a. Tongue deviation b. Intentional tremors (Parkinson’s disease) c. Plantar flexion d. Drooping eyelids
RATIONALE TEST: TENSILON = confirms myasthenic crisis or myasthenia gravis (If nay improvement after injection) (If it worsens, CHOLINERGIC effect: administer ANTICHOLINERGIC .. atropine sulfate) DRUG OF CHOICE: Mestinon or Neostigmine
5. When the nurse is assessing a 50 year old patient who has Cirrhosis of the liver, which of the following findings would indicate that the patient’s condition is worsening?
a. Positive Babinski’s sign (Stroke) (flexion: good prognosis) (fanning of toes: not intact) b. Visual fields loss c. Flapping hand tremors (Asterixis) d. Bibasilar lung crackles
RATIONALE: Fanning of the toes = there is an impairment or the neurologic system is not attached. ASTERIXIS: Flapping Hand tremors Complication of Liver Cirrhosis: Hypertension, Esophageal varices, Hepatic encephalopathy Post OR surgery involving the neck = bleed in the esophagus frequent swallowing / use penlight to lighten the oral cavity o Sengstaken-Blakemore Tube: control the bleeding of the esophageal varices o Hepatic Encepalopathy: Ammonia is delivered to the brain
Ammonia o LACTULOSE (laxative): a drug that binds the ammonia to promote excretion of ammonia - CEREBROVASCULAR = pampahilis sa plema - STROKE PATIENT / CVA - increase cranial pressure can lead to brain stem compression o NEOMYCIN SULFATE
6. To which of the following interventions would a nurse give priority in the care of patient admitted to the hospital with a suspected diagnosis of Guillain Barre Syndrome
a. Evaluate the level of consciousness every 15 minutes
b. Perform passive range of motion exercises every four hours c. Assess breath sounds every two hours d. Provide skin care every shift
RATIONALE Myasthenia Gravis: descending paralysis Present neurologic deficits because it is a degenerative disorder Guillan-Barre Syndrome: ascending paralysis; degenerative disorder (ABC) EQUIPMENT PREPARED AT BEDSIDE: Tracheostomy set
7. A nurse is caring for a client hospitalized with acute exacerbation of COPD. Which of the following laboratory values would the nurse expect to find/ note in the client
a. Increase oxygen saturation with exercise
b. Hypocapnia c. A hyperinflated chest on x-ray film d. A widened diaphragm noted on chest x-ray film
8. A nurse is caring for a client with a diagnosis of gout. Which of the following laboratory values would the nurse expect to find/ note in the client?
a. Uric acid level of 8mg/dl
b. Calcium level of 9mg/dl c. Phosphorus level of 3mg/dl d. Potassium level of 4mEq/l RATIONALE Probenecid: promotes excretion of uric acid Colchicine : long term management for gout Allupyoric: decreases uric acid synthesis Maalox: neutralizes uric acid Ranitidine: blocks hydrochloric acid secretion Omeprazole: inhibits the secretions of hydrochloric acid (30 mins before or after meals) Above 7 uric acid pt is candidate for gout arthritis
9. A nursing instructor asks a student to describe the pathophysiology that occurs in Cushing’s Disease. Which statement by the student indicates an accurate understanding of this disorder?
a. Cushing’s disease is characterized by an over secretion of glucocorticoid hormones
b. Cushing’s disease is characterized by an under secretion of glucocorticoid hormones c. Cushing’s disease is characerized by an over secretion of insulin d. Cushing’s disease is characterized by an under secretion of corticotropic hormones RATIONALE ANYTHING DOWN THE SOIL = Sodium : UP IN THE TREE = Potassium Phreochromocytome: tumor in adrenals (BMA TEST TO CONFIRM) : CHARACTERISTIC = high blood pressure
10. A three month old infant is diagnosed of having a communicating hydrocephalus. In helping the parents understand the physician’s explanation of the baby’s problem, the nurse should state:
a. Too much cerebrospinal fluid is produced within the ventricles of the brain (obstruction) b. The cerebrospinal fluid is prevented from proper absorption by a blockage in the ventricles of the brain (non-communicating) c. The part of the brain surfaces that normally absorbs cerebrospinal fluid after its production is not functioning adequately (absorption) d. There is a flow of cerebrospinal fluid between the brain cells and the ventricles which do not empty properly into the spinal cord
RATIONALE CSF is produced in the CHOROID PLEXUS 2 Lateral Ventricles Foramen of Monroe (3rd ventricle) Aqueduct of Sylvius (4th ventricle) Fourth ventricle subArachnoid space Foramen of Lushka and Magendie (stored) CSF = hydrocephalus Absorption of CSF in subarachnoid space Communicating type of hydrocephalus Obstruction in the flow of CSF in ventricular system Non communicating type of hydrocephalus) PROBLEMS OF INCREASED INTRACRANIAL PRESSURE Lesion, Tumor, Infarct, Aneurysm, Atriovenous malformation affecting the CEREBRUM DECORTICATION (better prognosis compared to DECEREBRATION) DECEREBRATION = involvement of brainstem (brainstem compression) (STROKE: prevent escalation of ICP: administer lactulose to decrease uric acid and prevent VALSAVA MANEUVER) Pons and medulla oblongata = CARDIAC AND RESPIRATORY CENTER Macewen’s sign = crack pat, dilated scalp base, frontal bossing, sun setting eyes (hydrocephalus) ILLUMINATING OF THE CHILD’S HEAD = trans-illumination (maklaro ang tubig sa ulo sa bata) increase Blood pressure and temp, Respiratory rate decrease, Acutely altered mental status , Irritability, Note for projectile vomiting, Seizures (BRAINS) B = Blood pressure increase R = Respiratory rate decrease A = Acutely altered mental status I = Irritability N = Note for projectile vomiting S = Seizures
11. In assessing a child with Croup, the nurse would expect to find a. Bronchospasm, whooping cough b. Expiratory stridor, crackles c. Laryngospasm, barking cough d. Productive cough, respiratory stridor
12. The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid?
a. Head turned to side (if there’s projectile vomiting: facilitate drainage)
b. Head midline c. Neck in neutral position (safe answer) d. Head of bed elevated 30-45 degrees
RATIONALE DO NOT FLEX OR HYPEREXTEND = CAN INCREASE THE ICP
13. The client is admitted to the hospital with a diagnosis of benigh prostatic hypertrophy, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse take the client’s vital signs and empties the urinary drainage bag, Which of the following assessment findings would indicate the need to notify the physician?
a. Red bloody urine
b. Urinary output of 200 ml greater than intake c. Blood pressure of 100/50 mmHg, pulse 130 beats per minute (hemorrhage / hypovolemic) d. Pain related to bladder spasms
14. A sweat chloride test is performed on a child with suspected diagnosis of cystic fibrosis. The nurse review the test results and determines that which of the following is a positive result for cystic fibrosis.
a. Chloride level of 20 mEq/L
b. Chloride level of 30 mEq/L c. Chloride level of 40 mEq/L d. Chloride level of 70 mEq/L
RATIONALE SWEAT CHLORIDE TEST: 70 mEq/L CHEST PHYSIOTHERAPHY: Before meals ( can stimulate vomiting if after meals )
15. The client is admitted with an exacerbation of Multiple Sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which of the following factors, if stated by the client, would the nurse assess as being unrelated to the exacerbations?
a. A stressful week at work
b. Ingestion of more fruits and vegetables c. A recent bout of a flu d. Inability to sleep well
16. Which of the following is a manisfestation of congenital hip dislocation?
a. Affected hip is abducted away from the unaffected leg
b. Affected hip is hyperextended c. Affected hip is in external rotation d. Affected leg is longer than the unaffected leg
17. Which of the manifestations, if reported by a patient, should a nurse recognize as supporting a diagnosis of meningitis?
a. Pain with neck flexion
b. Tingling of the lips (problem of calcium) c. Drooling of the saliva d. Weakness of the legs
RATIONALE BRUDZINSKI SIGN = Pain upon neck flexion (meningitis) KERNIG’S SIGN = Pain upon flexion
18. A 32 year old patient in an ambulatory care center is suspected of having an acoustic neuroma. Which of the following findings, if present in the patient, would support this diagnosis?
a. Diplopia b. Dysphagia c. Tinnitus d. Ataxia
19. A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of associated with this procedure. Which findings indicate spasm or occlusion of a cerebral artery by clot?
a. Nausea, vomiting, profuse sweating
b. Hemiplegia (body paralysis), seizures, decreasing level of consciousness c. Difficulty breathing or swallowing d. Tachycardia, tachypnea, hypotension (hypovolemic shock)
RATIONALE ISCHEMIC, EMBOLIC, HEMORRHAGIC TYPE OF STROKE = if ang clot maabots utok
20. A client is suspected of having amyotrophic lateral sclerosis. To confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the doctor to order
a. Electromyography b. Doppler scanning c. Doppler ultrasonography d. Angiography
