NUR 213 Test 2 Ch.1 - intervention is most important for the nurse to...

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NUR 213 Test 2 Ch.1

• The nurse is caring for the patient who has had an injury to the hypothala- mus. Which

intervention is most important for the nurse to implement?

Answer Close- ly control room temperature.

• The nurse differentiates the sympathetic from the parasympathetic nervous systems. Which

statement about the sympathetic system is accurate?

Answer The sympathetic system provides energy for "fight or flight" in stressful situations

• The nurse is assessing an 80-year-old patient. The nurse correctly attributes the slowed knee

jerk reflex with which age-related change?

Answer Degeneration of myelin sheath

• A student nurse questions the nurse about the difference between a quadri- plegic and a

tetraplegic patient. Which statement correctly describes tetraple- gia?

Answer Tetraplegia is the newer term for the old term quadriplegia.

• The nurse is performing a neurologic assessment on a patient. Which action should the nurse

take to adequately test the effectiveness for the hypoglossal nerve?

Answer Ask the patient to touch the tip of the tongue to each cheek.

• Which behavior causes the nurse to report a positive Romberg test?

Answer . The patient sways from side to side.

• While performing an assessment, the nurse taps a patient's knee and ob- serves that the

quadriceps muscle reflexively contracts. How should the nurse document this finding?

Answer Patellar reflex 2/5

• The nurse interprets the physician's finding of a grade of 2/5 on the Achilles tendon to mean

what has occurred?

Answer Normal response for the first and second sacral nerves

• Which reflex indicates an abnormality in the motor control pathways from the cerebral

cortex?

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Answer Babinski reflex

• The nurse is caring for a patient with a head injury. Over a time span of 30 minutes, the

nurse observes the following vital signs changes

Answer temperature from 97° to 98° F; pulse from 86 to 78 beats/min; respirations from 18 to 14 breaths/min; and blood pressure from 140/86 to 150/82. Which action is most important for the nurse to take?

Answer Notify the physician immediately.

• The patient is caring for a patient who spontaneously opens his eyes, localizes pain, and

carries out confused conversation. The nurse correctly documents which Glasgow Coma Scale (GCS) rating for this patient?

Answer 13

• The nurse is caring for a patient who requires neurologic checks. When performing an

assessment, how should the nurse best evaluate the patient's thinking?

Answer Ask the patient to add three numbers together in his head.

• The nurse is performing a neurologic assessment on a newly admitted patient with a head

injury. Which sign best indicates that the patient may have experienced a brainstem injury?

Answer Decerebrate posturing

• The nurse is assessing muscle strength in a fully conscious patient as part of a neurologic

assessment. Which technique should the nurse employ?-

Answer Press down on the patient's extended arms one at a time while the patient attempts to raise the arm.

• When feeding a patient with dysphagia with a left-sided hemiplegia, how should the nurse

position the patient?

Answer High Fowler

• Bladder training begins with scheduling the patient's toileting in what time increment?

Answer Every 2 hours

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