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Editing Voit Styles Font 5 Paragraph B 8 The nurse is assisting as a neurosurgeon examines a patient who has a positive Babinski reflex What assessment finding should the nurse expect to observe? a. The leg flexes when the patellar tendon is struck b. The leg extends when the patellar tendon is struck The big toe extends when the sole of the foot is stroked. d Toes curl downward when the sole of the foot is stroked. 9 When the nurse shines a light in a patient’s left pupil, both of the pupils constrict What type of response should the nurse document? a Direct b. Abnormal Consensual d. Accommodation 10. A patient opens the eyes to painful stimuli, makes incomprehensible sounds, and withdraws from pain. What should the nurse calculate this patient’s Glasgow Coma Scale score to be? a 2 b a 4 a d 8 C 1 The nurse is caring for an individual with a head injury and notes unequal pupils. Which term should the nurse use to document this finding? a. Aphasia b. Nystagmus Anisocoria d. Opthalmoplegia 2. The nurse is caring for a patient admitted to the emergency room after a motor vehicle crash Which assessment is most important for the nurse to complete? Babinski test b. Romberg test C Glasgow Coma Scale d Visual analogue scale 3 The nurse is caring for a patient who is scheduled for a CT scan of the brain because of new onset headaches. Which statement by the nurse is most accurate when preparing the patient for the scan? You must shampoo your hair thoroughly tonight to remove oil and dirt. 6 You will need to hold your head completely still during the examination You may take fluids until about 8 am. Then we will give you a special radiopaque drink. d. We will partially shave your head tonight so that electrodes can be ched securely 4. A patient is scheduled for a lumbar puncture which action should the nurse take when preparing this patient? a. Remove all jewelry b. Administer enemas until clear c Remove the patient’s dentures d. Assist the patient into a side-lying position 5 The nurse is providing post-procedure care for a patient recovering from a lumbar puncture Which order should the nurse anticipate for this patient? the patient NPO for 4 hours. Have the patient lie flat for 6 hours. Monitor the patient’s pedal pulses every 4 hours d. Keep the head of the bed elevated 30 degrees for 8 hours. A patient who is severely brain damaged has decerebrate posturing with extended extremities In which area of the of the brain should the nurse suspect the patient has sustained damage? Cerebrum celebrum Brain stem Cerebellum d Hypothalamus The nurse is caring for a patient who has had a stroke. The patient is unable to understand what the nurse is saying and appears frustrated What term should the nurse use to document this finding? Dysphagia Confusion Receptive aphasia d. Expressive aphasia Keep 6 I h CC Display Settings D Focus A D here to search
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