31. The nurse is caring for the patient with complex partialseizures. Which describes a focal onset with impaired awarenessseizure?
a. there is no loss of consciousness during seizure activity b.the patient may repeatedly pick at the linens c. There are usuallyinvolving more than one hemisphere d. They are usually related to abrain injury
32. A charge nurse is educating a newly hired nurse ondifferentiating pseudo dementia from dementia in elderly patients.Which statement by the new nurse indicates learning has takenplace?
a. patients with pseudo dementia experience poor attention anddecreased appetite b. patients with pseudo dementia experienceunchanged appetite and wandering c. patients with pseudo dementiaexperience disorientation and unchanged appetite d. patients withpseudo dementia experience decreased appetite and confabulation
33.While interviewing a victim of intimate partner violence thenurse determines that the survivors partner is using power andcontrol over the patient through coercion and threats. Whichpatient statement would lead the nurse to suspect this?
a. he will punch the wall and throw things if I don’t do what hetells me to do b. he doesn’t want me to talk with my friend andfamily c. he tells me he loves me so much he can’t stand the ideaof me talking to another man d. he says he will cut his throat if Iever leave with the kids
34 . A patient with parkinsons disease is admitted to thehospital for treatment of an exacerbation. Which nursinginterventions will be included in the patients plan of care. Selectall that apply.
a. cut patients food in small pieces b. provide high proteins,high carbs foods at meal time c. observe for aspiration pneumoniad. remind patients to use a wide based gait.
35. A patient with a herniated disk undergoes a laminectomyfollowing the surgery, how would the nurse position the patient onthe side?
a. placing a pillow between patients legs and turning the entirebody in a log roll b. having the patient turn by grasping thetrapeze and pulling the shoulders over c. have the legs flexedwhile turning to the side keeping the back straight d. keeping thepatient centered to bed and turning the patient 30 degree on theside
36. The nurse is caring for a patient with multiple sclerosis.The patient tells the nurse the hardest thing to deal with is thefatigue? When teaching the patient to reduce fatigue, what actionshould the nurse suggest?
a. increasing the dose of the diease-modifying drugs as neededb. avoiding naps during the day c. taking a warm bath at least oncea day d. resting in a temperature controlled room wheneverpossible
37. The nurse arrived at the scene of a patient falling off aladder. The victim is unconscious. Which action will the nursetakes first?
a. carefully remove the patient from the scene b. prepare thepatient for intubation c. assess for head bleeding and check theblood pressure d. stabilize the patients spinal cord
38. when teaching a patient with myasthenia gravis aboutmanagement of the disease, what should the nurse advise the patientto do?
a. perform necessary physically demanding activities in themorning b. consume high protein, low carbohydrates diet c.anticipate the need for weekly plasmaphoresis treatments d. advisethe patient to ambulate 60 feet on a daily basis
39. A patient who was adopted at birth is diagnosed withhuntingtons disease, when teaching the patient, spouse and childrenabout this disorder, the nurse will provide what information?
a. genetic testing to determine the risk for the children b.planning to place the patient in a long term nursing care facilityc. lifestyle changes to delay disease progression and complicationsd. drugs available to slow progression of disorder
40. the patient begins to experience a tonic-clonic seizure.Which of the following interventions should be included in the planof care?
a. turn the patient to the side b. restrain the patient c.remove the clothing patient is wearing d. place a padded tongueblade into the patients mouth
41. when obtain a health history and performing a physicalassessment for a patient with possible multiple sclerosis, whatshould the nurse be asking the patient?
a. question the patient about any leg weakness or spasm b.question the patient about any ptsosis c. question the patient ifthey have bradykinesia d. question the patient if they problemsbreathing
42. A patient is brought to the emergency department for astroke, thrombolytic therapy (tpa) is started as indicated perprotocol. Which manisfestation post transfusion would require thenurse to take immediate reaction?
a. nosebleed b. blood pressure at 180/100 mm hg c. intractableheadache d. productive cough
43. While a nurse is administering memantine (Namenda) to apatient. The family member asks. Why are you giving that pill?’What is the response by the nurse?
a. memantine works by blocking the release of dopamine b.memantine works by decreasing the release of glutamane c. memantineworks by blocking the reuptake of norepinephrine d. memantine worksby decreasing the breakdown of acetycholine
44. the patient with a c6 spinal cord injury is administered tothe emergency department complaining of a severe pounding headacheand have a BP of 180/110. Which intervention should the nurseimplement?
a. assess for blocked foley catheter b. assess pupil response c.assess the patient’s medication history d. assess the change inLOC
45. In planning discharge instructions for a patient withtrigeminal neuralgia. The nurse knows to include information aboutfactors that precipitate an attack?
a. massage the affected side to relieve the pain b. avoidwashing the face with hot water c. drink cold fluids rather thanhot fluids d. eat small and frequent meals
46. The nurse is assessing lab work of a patient who has beentaking clozapine (clozaril) for four weeks. Which assessmentfinding should be reported to the physician immediately?
a. decreased hemoglobin b. increased salivation c. recent weightgain d. leukopenia
47. When interviewing the family, which assessment questionwould be most useful to differentiate delirium from dementia in apatient admitted to the hospital after experiencing increasedconfusion at home?
a. how long have you noticed the confusion b. have you noticedincreased agitation sundown c. Can your family member manage theirown finances d. Is the confusion worse or better in the morning
48. A 65 year old male has been admitted to the ICU followingsurgical resection of the bowel. The nurse is assessing the patientfor signs of delirium. Which behavior would indicate that thepatient is becoming delirious?
a. the patient has trouble performing complex motor functions b.the patient identifies his fork as a spoon c. the patient is unableto speak d. the patient removes his surgical bandage and pulls atthe IV.
49. During a nursing assessment of a new admission which commentmade by the patient would suggest the patient may have a paranoidpersonality?
a. patient states that he has gotten into trouble with thepolice, but it is not his fault b. patient insists on having anexact schedule and needs everything to be orderly c. patientinsists his co workers can’t be trusted and knows others are out toget him d. patient states he would like to find a job but isuncomfortable around others.
