Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
You admit a client on day 1. After several days off, you are reassigned the same client. Click the tabs to review vital signs and nurse notes to review the client's progression.
Vital Signs Assessment Day 1:
Temperature 37.5° C (99.5° F) Blood pressure 198/96 mm Hg Heart rate 112/min
Respiratory rate 22/min
Oxygen saturation 96% on room air Day 7:
Temperature 38° C (100,4° F) Blood pressure 166/70 mm Hg Heart rate 68/min
Respiratory rate 20/min
Oxygen saturation 97% on room air
Question: For each client finding, click to specify if the finding could indicate Parkinson's disease, stroke, and/or multiple sclerosis. Each finding can support more than one disease process. Click the tabs at the top of the page for information about your client.
A. Blood pressure
Blood pressure Stroke and Multiple Sclerosis are correct because both conditions can cause hypertension due to increased intracranial pressure or autonomic dysfunction. Parkinson's Disease is incorrect because it does not affect blood pressure directly.
B. Facial symmetry
Facial symmetry Stroke is correct because it can cause facial droop or paralysis due to damage to the cranial nerves or brainstem. Parkinson's Disease and Multiple Sclerosis areincorrect because they do not cause facial asymmetry, but may cause facial rigidity or masklike expression in Parkinson's Disease or facial numbness or pain in Multiple Sclerosis.
C. Cognitive function
Cognitive function Parkinson's Disease, Stroke and Multiple Sclerosis are correct because all three conditions can impair cognitive function due to degeneration of neurons,ischemia of brain tissue or demyelination of nerve fibers. Cognitive impairment may manifest as memory loss, confusion, dementia, aphasia, apraxia or agnosia.
D. Mobility status
Mobility status Parkinson's Disease, Stroke and Multiple Sclerosis are correct because all three conditions can affect mobility status due to muscle weakness, spasticity, rigidity, tremors, ataxia, hemiplegia or paraplegia. Mobility impairment may affect gait, balance, coordination or posture.
E. Speech
Speech Parkinson's Disease, Stroke and Multiple Sclerosis are correct because all three conditions can affect speech due to dysarthria, dysphonia, dysphagia, aphasia or dysfluency. Speech impairment may affect articulation, volume, tone or fluency.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Similar Questions
When providing education to a student nurse about ways to avoid increased intracranial pressure, which of the following will the nurse include in the instructions?(Select All that Apply.)
A. Consult with dietary
Correct. Consulting with dietary can help prevent constipation, which can increase intracranial pressure by straining.
B. Keep the client's head at 25 degrees or lower
Correct. Keeping the client's head at 25 degrees or lower can help reduce venous pressure and facilitate cerebral drainage.
C. Dim the lights
Correct. Dimming the lights can help reduce sensory stimulation and prevent agitation, which can increase intracranial pressure.
D. A stool softener will be ordered
Correct. A stool softener can help prevent constipation and straining, which can increase intracranial pressure.
E. Keep a yankaur suction set up at bedside
A 70year old client diagnosed with a hemorrhagic stroke was admitted 1 day ago. His
medical history includes hypertension, osteoarthritis, and type 2 diabetes. He has right sided
paralysis, garbled speech, and a weak cough reflex. This morning he is restless. Vital signs are Blood Pressure 160/80, pulse 110, respirations 24, oxygen saturation 90% Which of the following Interventions will the nurse take to avoid complications? Select all that apply
Select All that Apply)
A. Apply oxygen
Correct. Applying oxygen can help improve the client's oxygen saturation and prevent hypoxia, which can worsen the brain injury.
B. Monitor blood pressure
Correct. Monitoring blood pressure is essential for a client with a hemorrhagic stroke, as hypertension can increase the risk of bleeding and rebleeding.
C. Implement seizure precautions
Correct. Implementing seizure precautions can protect the client from injury and aspiration in case of a seizure, which can occur due to increased intracranial pressure or irritation of the brain tissue.
D. Provide oral fluids
Incorrect. Providing oral fluids is contraindicated for a client with a weak cough reflex, as it can increase the risk of aspiration pneumonia.
E. Turn the client twice each shift
A nurse is caring for a client with a closed skull injury who has an intracranial pressure (ICP) reading consistently over 20 mmHg, According to the MonroeKellie Doctrine, If Intracranial pressure continues to Increase, what will occur? Select All that Apply.
A. Fracture of the skull
Fracture of the skull is not a consequence of increased ICP, but rather a possible cause of it. A fracture can allow blood or cerebrospinal fluid (CSF) to leak into the cranial cavity and increase the pressure inside the skull. This is an incorrect choice.
B. Ischemia
Ischemia is a condition where the blood supply to a tissue or organ is reduced or blocked, resulting in oxygen deprivation and tissue damage or death. Increased ICP can cause ischemia by compressing blood vessels and reducing cerebral perfusion pressure (CPP), which is the difference between mean arterial pressure (MAP) and ICP. CPP must be maintained above 60mmHg to ensure adequate blood flow to the brain. This is a correct choice.
C. Hypotension
Hypotension is a condition where the blood pressure is abnormally low, which can impair organ function and perfusion. Increased ICP can cause hypotension by stimulating the vagus nerve, which slows down the heart rate and lowers the cardiac output and MAP. This reduces the CPP and increases the risk of ischemia. This is a correct choice.
D. Hyperventilation
Hyperventilation is a condition where the breathing rate and depth are increased, resulting in lower levels of carbon dioxide (CO2) in the blood. Increased ICP can cause hyperventilation by stimulating the respiratory center in the brainstem, which tries to lower the CO2 levels and increase the pH of the blood. This causes cerebral vasoconstriction and reduces ICP temporarily, but also reduces CPP and increases the risk of ischemia. This is a correct choice.
E. Increase in Glasgow Coma Score