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 noticed increased agitation sundown c. Can your familymember manage their own finances d. Is the confusion worse orbetter 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.
