ATI Med-Surg Neurosensory Quiz with
|\ |\ |\ |\ |\
verified answers |\
A nurse is reinforcing discharge teaching with the family of a client who has
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
a new diagnosis of a seizure disorder. The nurse should instruct the client's
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
family to take which of the following actions first during the event of a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
seizure?
A. Reorient the client.
|\ |\ |\
B. Protect the client's head.
|\ |\ |\ |\
C. Loosen constrictive clothing.
|\ |\ |\
D. Turn the client on his side.
|\ |\ |\ |\ |\ |\
B. Protect the client's head
|\ |\ |\ |\
Rationale: The nurse should apply the safety and risk reduction priority-
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
setting framework. This framework assigns priority to the factor or situation
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
posing the greatest safety risk to the client. When there are several risks to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client safety, the one posing the greatest threat is the highest priority. The
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
framework, or nursing knowledge to identify which risk poses the greatest
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
threat to the client. The client is at greatest risk for injury from hitting his
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
head; therefore, the first action the nurse should take is to protect the client's
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
head from injury. The family should reorient the client as he regains
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
consciousness following a seizure; however, another action is the priority. |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
The family should loosen constrictive clothing to protect the client from
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
injury during a seizure; however, another action is the priority. The family
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
should turn the client on his side to protect the client from injury during a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
seizure; however, another action is the priority.
|\ |\ |\ |\ |\ |\
,A nurse is reinforcing teaching with a group of client's about transient
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ischemic attacks (TIAs). Which of the following information should the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse include in the teaching?
|\ |\ |\ |\
A. A TIA can cause irreversible hemiparesis.
|\ |\ |\ |\ |\ |\
B. A TIA can be the result of cerebral bleeding.
|\ |\ |\ |\ |\ |\ |\ |\ |\
C. A TIA can cause cerebral edema.
|\ |\ |\ |\ |\ |\
D. A TIA can precede an ischemic stroke.
|\ |\ |\ |\ |\ |\ |\
D. A TIA can precede an ischemic stroke.
|\ |\ |\ |\ |\ |\ |\
Rationale: TIAs are considered a manifestation of advanced atherosclerotic
|\ |\ |\ |\ |\ |\ |\ |\ |\
disease and often precede an ischemic stroke. Manifestations of a TIA
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
include loss of vision in one eye, inability to speak, transient hemiparesis,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
vertigo, diplopia, numbness, and weakness. TIAs do not produce edema of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the cerebrum. Cerebral edema can be the result of a stroke. A hemorrhagic
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
stroke can be the result of cerebral bleeding. TIAs are caused by a temporary
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
reduction of oxygen supply to the brain, such as from a thromboembolism
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
or cerebral vasospasm. TIAs are brief episodes of a neurologic deficit that last
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
less than 24 hr after onset without any permanent disabilities.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
A nurse is collecting data from a client following a recent head injury.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Which of the following findings should the nurse recognize as a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
manifestation of increased intracranial pressure? |\ |\ |\ |\
A. Widened pulse pressure
|\ |\ |\
B. Tachycardia
|\
C. Periorbital edema
|\ |\
D. Decrease in urine output
|\ |\ |\ |\
A. Widened pulse pressure
|\ |\ |\
, Rationale: A widening of the pulse pressure, the difference between the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
systolic and diastolic pressure, is a manifestation of increased intracranial
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
pressure. Other manifestations include pupil changes, change in the level of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
consciousness, and nausea and vomiting. Tachycardia can be a manifestation |\ |\ |\ |\ |\ |\ |\ |\ |\
of hypovolemia; however, bradycardia is a manifestation of increased
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
intracranial pressure. Periorbital edema can occur following eye trauma or a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
craniotomy; however, it is not a manifestation of increased intracranial
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
pressure. A decrease in urine output can be a manifestation of hypovolemia;
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
however, it is not a manifestation of increased intracranial pressure.
|\ |\ |\ |\ |\ |\ |\ |\ |\
A nurse is reviewing the medical history of a client who is scheduled for a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
magnetic resonance imaging (MRI) examination of the cervical vertebra. The
|\ |\ |\ |\ |\ |\ |\ |\ |\
nurse should alert the provider to which of the following information in the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client's history is a contraindication to the procedure?
|\ |\ |\ |\ |\ |\ |\
A. The client has a new tattoo.
|\ |\ |\ |\ |\ |\
B. The client is unable to sit upright.
|\ |\ |\ |\ |\ |\ |\
C. The client has a history of peripheral vascular disease.
|\ |\ |\ |\ |\ |\ |\ |\ |\
D. The client has a pacemaker.
|\ |\ |\ |\ |\
D. The client has a pacemaker.
|\ |\ |\ |\ |\
Rationale: An MRI uses strong magnets and radio waves that are evaluated
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
using computer technology to view three-dimensional images of the body.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Since an MRI is magnetically generated, it is not indicated for use in the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
presence of certain medical implants. Clients who have cerebral aneurysm
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
because the strong magnetic force can interfere with these devices and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
obscure surrounding anatomical structures. An MRI uses strong magnets and
|\ |\ |\ |\ |\ |\ |\ |\ |\
radio waves that are evaluated using computer technology to view three-
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
dimensional images of the body. Peripheral vascular disease is not a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
contraindication for an MRI. The client who is unable to sit upright is able |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
to obtain an MRI because the client does not need to be in an upright
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
|\ |\ |\ |\ |\
verified answers |\
A nurse is reinforcing discharge teaching with the family of a client who has
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
a new diagnosis of a seizure disorder. The nurse should instruct the client's
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
family to take which of the following actions first during the event of a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
seizure?
A. Reorient the client.
|\ |\ |\
B. Protect the client's head.
|\ |\ |\ |\
C. Loosen constrictive clothing.
|\ |\ |\
D. Turn the client on his side.
|\ |\ |\ |\ |\ |\
B. Protect the client's head
|\ |\ |\ |\
Rationale: The nurse should apply the safety and risk reduction priority-
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
setting framework. This framework assigns priority to the factor or situation
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
posing the greatest safety risk to the client. When there are several risks to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client safety, the one posing the greatest threat is the highest priority. The
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
framework, or nursing knowledge to identify which risk poses the greatest
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
threat to the client. The client is at greatest risk for injury from hitting his
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
head; therefore, the first action the nurse should take is to protect the client's
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
head from injury. The family should reorient the client as he regains
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
consciousness following a seizure; however, another action is the priority. |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
The family should loosen constrictive clothing to protect the client from
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
injury during a seizure; however, another action is the priority. The family
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
should turn the client on his side to protect the client from injury during a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
seizure; however, another action is the priority.
|\ |\ |\ |\ |\ |\
,A nurse is reinforcing teaching with a group of client's about transient
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ischemic attacks (TIAs). Which of the following information should the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse include in the teaching?
|\ |\ |\ |\
A. A TIA can cause irreversible hemiparesis.
|\ |\ |\ |\ |\ |\
B. A TIA can be the result of cerebral bleeding.
|\ |\ |\ |\ |\ |\ |\ |\ |\
C. A TIA can cause cerebral edema.
|\ |\ |\ |\ |\ |\
D. A TIA can precede an ischemic stroke.
|\ |\ |\ |\ |\ |\ |\
D. A TIA can precede an ischemic stroke.
|\ |\ |\ |\ |\ |\ |\
Rationale: TIAs are considered a manifestation of advanced atherosclerotic
|\ |\ |\ |\ |\ |\ |\ |\ |\
disease and often precede an ischemic stroke. Manifestations of a TIA
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
include loss of vision in one eye, inability to speak, transient hemiparesis,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
vertigo, diplopia, numbness, and weakness. TIAs do not produce edema of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the cerebrum. Cerebral edema can be the result of a stroke. A hemorrhagic
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
stroke can be the result of cerebral bleeding. TIAs are caused by a temporary
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
reduction of oxygen supply to the brain, such as from a thromboembolism
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
or cerebral vasospasm. TIAs are brief episodes of a neurologic deficit that last
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
less than 24 hr after onset without any permanent disabilities.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
A nurse is collecting data from a client following a recent head injury.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Which of the following findings should the nurse recognize as a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
manifestation of increased intracranial pressure? |\ |\ |\ |\
A. Widened pulse pressure
|\ |\ |\
B. Tachycardia
|\
C. Periorbital edema
|\ |\
D. Decrease in urine output
|\ |\ |\ |\
A. Widened pulse pressure
|\ |\ |\
, Rationale: A widening of the pulse pressure, the difference between the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
systolic and diastolic pressure, is a manifestation of increased intracranial
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
pressure. Other manifestations include pupil changes, change in the level of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
consciousness, and nausea and vomiting. Tachycardia can be a manifestation |\ |\ |\ |\ |\ |\ |\ |\ |\
of hypovolemia; however, bradycardia is a manifestation of increased
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
intracranial pressure. Periorbital edema can occur following eye trauma or a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
craniotomy; however, it is not a manifestation of increased intracranial
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
pressure. A decrease in urine output can be a manifestation of hypovolemia;
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
however, it is not a manifestation of increased intracranial pressure.
|\ |\ |\ |\ |\ |\ |\ |\ |\
A nurse is reviewing the medical history of a client who is scheduled for a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
magnetic resonance imaging (MRI) examination of the cervical vertebra. The
|\ |\ |\ |\ |\ |\ |\ |\ |\
nurse should alert the provider to which of the following information in the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client's history is a contraindication to the procedure?
|\ |\ |\ |\ |\ |\ |\
A. The client has a new tattoo.
|\ |\ |\ |\ |\ |\
B. The client is unable to sit upright.
|\ |\ |\ |\ |\ |\ |\
C. The client has a history of peripheral vascular disease.
|\ |\ |\ |\ |\ |\ |\ |\ |\
D. The client has a pacemaker.
|\ |\ |\ |\ |\
D. The client has a pacemaker.
|\ |\ |\ |\ |\
Rationale: An MRI uses strong magnets and radio waves that are evaluated
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
using computer technology to view three-dimensional images of the body.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Since an MRI is magnetically generated, it is not indicated for use in the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
presence of certain medical implants. Clients who have cerebral aneurysm
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
because the strong magnetic force can interfere with these devices and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
obscure surrounding anatomical structures. An MRI uses strong magnets and
|\ |\ |\ |\ |\ |\ |\ |\ |\
radio waves that are evaluated using computer technology to view three-
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
dimensional images of the body. Peripheral vascular disease is not a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
contraindication for an MRI. The client who is unable to sit upright is able |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
to obtain an MRI because the client does not need to be in an upright
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
