Tiêu đề PRETEST-NEURO-KEY(NOV 2024).pdf ✅

TOPRANK REVIEW ACADEMY INC 1 * NLE * NCLEX * CGFNS * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY * PRE-TEST NEUROLOGIC NURSING NAME: 1. Nurse Elise is currently assessing a 35/M patient with cerebellar stroke. She is currently assessing the patient’s response to pain. Which of the following techniques should she use first? a. Pressure on orbital rim b. SCM pinch c. Nailbed pressure d. Sternal rub 2. Elise is now monitoring the client’s vital signs. Which of the following trend in vital signs indicate brain herniation? a. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure b. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure c. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure d. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure 3. Which of the following situations indicates that the post-stroke patient understood the health teaching? a. Patient can do bent-over press against the wall but with decreased repetition and intensity b. Patient blows her nose with sterile towel c. Patient coughs vigorously to release secretions that may cause atelectasis d. When the patient proceeds from lying in bed to sitting, she performs exhalation 4. Nurse Maya is currently monitoring a patient who sustained a head injury when a clear fluid was seen to be leaking from the nose. Which of the following indicates that this is NOT cerebrospinal fluid? a. Clear and colorless b. Same consistency as water c. Only small amount of proteins present d. Clear and tests negative for glucose 5. Helena is a 35 year old athlete who sustained spinal cord injury. Which of the following nursing interventions is NOT recommended? a. Keeping the linens wrinkle-free under the client b. Preventing unnecessary pressure on the lower limbs c. Limiting bladder catheterization to once every 12 hours d. Turning and repositioning the client at least every 2 hours 6. A post-angiography patient suddenly presented with thrombotic occlusion of arteries that supply the cervical spine. Which of the following indicated spinal shock? a. Patellar reflex: +4 b. Presence of brachioradialis reflex c. Muscle grading of the upper extremities: 0 d. During urination, the detrusor muscle that surrounds the bladder contracts while the internal urethral sphincter relaxes. 7. Fely is a 50 year old with a history of status epilepticus. On her 5th hospital day, she suddenly lost consciousness and her muscles stiffened with jerky movements. Which of the following interventions is UNSAFE for the patient? a. Loosening restrictive clothing. b. Removing the pillow and raising padded side rails. c. Positioning the client to the side, if possible, with the head flexed forward. d. None of the above. 8. If Elena sustains a complete right sided hemiparesis from an ischemic stroke, which of the following assessment findings would you expect? a. Response to the question How are you today: “You know that smoodle pinkered and that I want to get him round and take care of him like you want before.” b. Muscle grading: 0 on upper extremities only c. Elena can no longer perform sewing with her right hand but can walk independently d. Elena has pill rolling tremors on her right hand 9. Which of the following behaviors of the family denotes that they understood the measures to help a client with an infarct on the left occipital lobe. a. The family prevents him from using eyeglasses b. Client’s phone, comb, and other essentials are placed on the patient’s left side c. The family approach patients from the right side d. Family consistently reminds patient to turn his head to the left to scan the lost visual field. 10. Nurse Ely is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully? A. Gets angry with family if they try to help her transfer from wheelchair to bed B. Experiences bouts of suicidality C. Has difficulty with using the cane for walking D. Consistently uses adaptive equipment in dressing self 11. A 16 year old client was rushed to the hospital due to an MVA. As you monitor the his ICP, you see an upward trend. Which of the following should you do FIRST a. Administed 1g of Mannitol as ordered b. Increased ventilator rate to 22 bpm c. Administer 100 mg of phenytoin as ordered