1. A nurse is teaching a wellness class and is covering the warning signs of stroke. A patient
asks, "What is the most important thing for me to remember?" Which is an appropriate
response by the nurse?
1. "Know your family history."
2. "Keep a list of your medications."
3. "Be alert for sudden weakness or numbness."
4. "Call 911 if you notice a gradual onset of paralysis or confusion."
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2. A patient is placed in ventilator support with the diagnosis of botulism and failure to thrive.
Which nursing actions would be most appropriate for this patient?
Select all that apply.
1. maintaining intravenous fluids at KVO (keep vein open)
2. assessing bowel sounds once a shift
3. referring the patient for a physical therapy consult
4. recording the patient's ongoing calorie count
5. assessing the patient's urinary output every hour
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3. Which of the following is the priority nursing diagnosis for a patient diagnosed with a spinal
cord injury?
1. Fluid Volume Deficit
2. Impaired Physical Mobility
3. Ineffective Airway Clearance
4. Altered Tissue Perfusion
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4. A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate
for the nurse to include in patient and family teaching?
Select all that apply.
1. how to use a sign board
2. transfer techniques
3. information about impulse control
4. time adjustment to complete activities
5. safety precautions for transferring
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5. A patient has the nursing diagnosis of Impaired Swallowing and complains of frequent
heartburn. What is the most appropriate action by the nurse?
1. Assist the patient in maintaining a sitting position for 30 minutes after the meal.
2. Teach the patient the "chin tuck" technique when swallowing.
3. Check the patient's mouth for pocketing of food.
4. Assist the patient to a 90-degree sitting position, or as high as tolerated, during meals.
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6. A patient with a spinal cord injury at the T1 level complains of a severe headache and an
"anxious feeling." Which is the most appropriate initial reaction by the nurse?
1. Try to calm the patient and make the environment soothing.
2. Assess for a full bladder.
3. Notify the healthcare provider.
4. Prepare the patient for diagnostic radiography.
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7. A patient hospitalized with a known AV malformation begins to complain of a headache and
becomes disorientated. Which is the most appropriate action by the nurse?
1. Recommend to the family members that they start to look for a long-term care facility.
2. Prepare to give aspirin or a "clot buster."
3. Prepare the patient for surgery.
4. Document the changes and monitor closely.
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8. A school nurse is called after a student falls down a flight of stairs. The student is breathing,
but unconsciousness. After calling the ambulance, which is the most appropriate action by the
nurse?
1. Protect the patient's neck and head from any movement.
2. Place the patient on his side to prevent aspiration.
3. Immobilize the neck,,securing the head.
4. Try to rouse the patient by gently shaking his shoulders.
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9. A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore."
Which is the most appropriate action by the nurse?
1. Remind the patient of her injury and try to comfort her.
2. Call the healthcare provider and get an order for radiologic evaluation.
3. Prepare the patient for surgery, as her condition is worsening.
4. Explain to the patient that this could be a common, temporary problem.
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10. A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which
of the following actions is the nurse responsible for when caring for this patient?
Select all that apply.
1. modifying the traction weights as needed
2. assessing the patient's skin integrity
3. applying the traction upon admission
4. administering pain medication
5. providing passive range of motion
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11. The nurse is educating a patient and the family about different types of stabilization
devices. Which statement by the patient indicates that the patient understands the benefit of
using a halo fixation device instead of Gardner-Wells tongs?
1. "I will have less pain if I use the halo device."
2. "The halo device will allow me to get out of bed."
3. "I am less likely to get an infection with the halo device."
4. "The halo device does not have to stay in place as long."
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12. A post-stroke patient is going home on oral Coumadin (warfarin). During discharge
teaching, which statement by the patient reflects an understanding of the effects of this
medication?
1. "I will stop taking this medicine if I notice any bruising."
2. "I will not eat spinach while I'm taking this medicine."
3. "It will be OK for me to eat anything, as long as it is low fat."
4. "I'll check my blood pressure frequently while taking this medication."
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13. A patient with a spinal cord injury was given IV Decadron (dexamethasone) after arriving in
the emergency department. The patient also has a history of hypoglycemia. During the
hospital stay, the nurse would expect to see which of the following?
1. increased episodes of hypoglycemia
2. possible episodes of hyperglycemia
3. no change in the patient's glycemic parameters
4. both hyper- and hypoglycemic episodes
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14. Which of the following nursing actions is appropriate for preventing skin breakdown in a
patient who has recently undergone a laminectomy?
1. Provide the patient with an air mattress.
2. Place pillows under patient to help patient turn.
3. Teach the patient to grasp the side rail to turn.
4. Use the log roll to turn the patient to the side.
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15. Which of the following is the priority nursing diagnosis for the patient who has undergone
surgery for a spinal fusion?
1. Acute Pain
2. Impaired Mobility
3. Risk for Infection
4. Risk for Injury
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16. A patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood
pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a
blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in
reacting to light. These findings suggest which of the following?
1. impending brain death
2. decreasing intracranial pressure
3. stabilization of the patient's condition
4. increased intracranial pressure
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17. A hospitalized patient has become unresponsive. The left side of the body is flaccid. The
attending physician believes the patient may have had a stroke (CVA). What is the nurse's
priority intervention?
1. Move the patient to the critical care unit.
2. Assess blood pressure.
3. Assess the airway and breathing.
4. Observe urinary output.
18. A patient whose status is post-stroke (CVA) has severe right-sided weakness. Physical
therapy recommends a quad cane. Which of the following is proper use of the cane by the
patient?
1. The patient holds the cane in the left hand. The patient moves the cane forward first, then the right
leg, and then the left leg.
2. The cane is held in either hand and moved forward at the same time as the left leg. Then the
patient drags the right leg forward.
3. The patient holds the cane in the right hand for support. The patient moves the cane forward first,
then the left leg, and then the right leg.
4. The patient holds the cane in the left hand. The patient moves the left leg forward first, then moves
the cane and the right leg forward together.
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19. The family of a patient who has had a brain attack (CVA) asks if the patient will ever talk
again. The nurse should do which of the following?
1. Explain that the patient's speech will return to normal with time.
2. Explain that it is difficult to know how far the patient will progress.
3. Tell the family that nurses cannot discuss such issues. Tell them to ask the physician.
4. Tell the family what they see today is all they can expect.
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20. The nurse is teaching regarding risk factors for stroke (CVA). The greatest risk factor is
which of the following?
1. diabetes
2. heart disease
3. renal insufficiency
4. Hypertension
21. The nurse recognizes that the most common type of brain attack (CVA) is related to which
of the following?
1. ischemia
2. hemorrhage
3. headache
4. Vomiting
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22. When caring for a patient admitted post-stroke (CVA) who has altered consciousness, the
nurse should place the patient in which position?
1. side-lying
2. supine
3. prone
4. semi-Fowler's
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23. The nurse must be alert to complications in the patient who has suffered a ruptured
intracranial aneurysm. The nurse should assess the patient for signs of which of the
following?
Select all that apply.
1. headache
2. hydrocephalus
3. rebleeding
4. vasospasm
5. stiff neck
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24. The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse
realizes that some nursing actions are contraindicated with IICP. Which nursing action should
be avoided?
1. Reposition the patient every two hours.
2. Position the patient with the head elevated 30 degrees.
3. Suction the airway every two hours per standing orders.
4. Provide continuous oxygen as ordered.
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25. Prodromal manifestations prior to an intracranial aneurysm rupture could be recognized by
the nurse as which of the following?
Select all that apply.
1. visual deficits
2. headache
3. mild nausea
4. dilated pupil
5. stiff neck
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26. Which patient is at highest risk for a spinal cord injury?
1. 18-year-old male with a prior arrest for driving while intoxicated (DWI)
2. 20-year-old female with a history of substance abuse
3. 50-year-old female with osteoporosis
4. 35-year-old male who coaches a soccer team
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27. The nurse understands that when the spinal cord is injured, ischemia results and edema
occurs. How should the nurse explain to the patient the reason that the extent of injury cannot
be determined for several days to a week?
1. "Tissue repair does not begin for 72 hours."
2. "The edema extends the level of injury for two cord segments above and below the affected level."
3. "Neurons need time to regenerate so stating the injury early is not predictive of how the patient
progresses."
4. "Necrosis of gray and white matter does not occur until days after the injury."
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28. A patient is recovering following a carotid endarterectomy. The blood pressure has risen
this morning to 168/60. The nurse should do which of the following?
1. Recheck the blood pressure and make sure the correct size cuff was used. Then compare the trend
of blood pressure readings and call the physician now.
2. Recheck the blood pressure every hour and report this change to the physician when he or she
makes rounds the next time.
3. Record the blood pressure and find out who took this reading. Have that staff member demonstrate
his or her blood pressure procedure and offer tips to obtain more accurate readings.
4. Check the standing orders and see if there is a medication ordered p.r.n. for lowering blood
pressure. If so, administer it and document the action.
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29. A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that
the patient should not develop a full bladder because what emergency condition can occur if it
is not corrected quickly?
1. autonomic dysreflexia
2. autonomic crisis
3. autonomic shutdown
4. autonomic failure
30. While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the
bed, removes compression stockings, and continues to assess vital signs every two to three
minutes while searching for the cause in order to prevent loss of consciousness or death. By
practicing these interventions, the nurse is avoiding the most dangerous complication of
autonomic dysreflexia, which is which of the following?
1. hypoxia
2. bradycardia
3. elevated blood pressure
4. Tachycardia
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31. A lumbar puncture (LP) is done on a patient to rule out a spinal cord tumor. The
cerebrospinal fluid (CSF) is xanthochromic, has increased protein, no cells, and clots
immediately. What syndrome do these findings describe?
1. Glasgow's syndrome
2. Froin's syndrome
3. cord tumor syndrome
4. reflex syndrome
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32. The nurse realizes that the goal of surgery for a patient with a secondary metastatic spinal
cord tumor is
1. complete removal of the tumor and affected spinal cord tissue.
2. eradication of the tumor with excision and drainage.
3. tumor excision to reduce cord compression.
4. exploration to visualize the tumor and obtain a biopsy.
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33. A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities
and complete paralysis of the lower part of the body. The nurse should use which medical
term to adequately describe this in documentation?
1. hemiplegia
2. paresthesia
3. paraplegia
4. Quadriplegia
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34. The patient is admitted with injuries that were sustained in a fall. During the nurse's first
assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in
the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine
output, and palpation of a distended bladder. These signs are consistent with which of the
following?
1. paralysis
2. spinal shock
3. high cervical injury
4. temporary hypovolemia
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35. An unconscious patient receiving emergency care following an automobile crash accident
has a possible spinal cord injury. What guidelines for emergency care will be followed?
Select all that apply.
1. Immobilize the neck using rolled towels or a cervical collar.
2. The patient will be placed in a supine position
3. The patient will be placed on a ventilator.
4. The head of the bed will be elevated.
5. The patient's head will be secured with a belt or tape secured to the stretcher.
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36. A patient has manifestations of autonomic dysreflexia. Which of these assessments would
indicate a possible cause for this condition?
Select all that apply.
1. hypertension
2. kinked catheter tubing
3. respiratory wheezes and stridor
4. diarrhea
5. fecal impaction
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37. An industrial nurse is conducting a class to teach methods to prevent back pain. What is
the correct of steps for lifting heavy objects?
Choice 1. Spread the feet apart to broaden the base of support.
Choice 2. Use large leg muscles to push when lifting.
Choice 3. Stand as closely as possible to the object to be moved.
Choice 4. Rolling or pushing the obect insrtead of lifting.
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38. Of the following, which groups are the most at risk for bacterial meningitis?
Select all that apply.
1. older adults
2. pregnant women
3. military recruits
4. college students
5. low-income