- slightly down and forward as if pointing at nose Correct
Answers Insert the speculum of the otoscope in which
direction?
- stuporous: ↓ response to verbal cues or pain
- mute Correct Answers Findings of someone who has altered
consciousness?
- awakeness?
- speech?
1 because mild dementia = difficulty learning new skills and
forgetfulness Correct Answers A home health with AD and
mild dementia has a new prescription for Aricept. What nursing
action will be most effective in ensuring compliance with
medication?
1. having the patient's spouse administer the meds
2. calling the patient daily with a reminder to take the med
3. posing reminders to take the meds in the patient's house
4. setting the meds up weekly in the medication box
1-1.5cm
don't touch ear canal (sensitive) Correct Answers The
speculum of the otoscope must be inserted ___ cm. Be sure not
to do what?
1-2 Correct Answers myelogram headache may be healed in
how many days with rest and fluids? either way, contact HCP
1. caregiver respite
,2. memory aids (stimulation) Correct Answers 2 main reason
to take AD patient to ambulatory care setting
1. eyelids (no ptosis)
2. pupil constriction
3. ocular movements Correct Answers what 3 things does the
oculomotor CN do?
1. injections may hurt
2. headache may occur after procedure but should resolve in 1-2
days with rest and fluids but should be reported to HCP. Correct
Answers 2 warnings for patients with myelograms?
1. loud tapping noises intermittently
2. no metal in clothing (ensure this yourself)
3. Be still
4. Claustrophobia Correct Answers Warn MRI patients that
(4T):
1. Surgery and treatments (hospitalizations, etc): know details
2. Medications
3. Past health history (osteoporosis, falls, etc) Correct Answers
What important health information (subjective data) should be
asked in an MS assessment?
1) assess for pain, anxiety, temperature change.
2) attempts should be made to identify and manage
environmental triggers while avoiding the use of physical and
pharmacologic restraints. Correct Answers If behavior is a
problem with an AD patient, what should you do?
3 because you need more complete information before making
any decision. The provider may order a CT to rule out a disease
process or injury but not you. restraints are last resort Correct
Answers a 78 yo patient presents with a hand injury but when
asked how it happened, the patient was confused and could not
remember. When a nurse completed the MMSE patient could
not answer most questions correctly. What is the next best action
the nurse should take?
1. immediately complete a head CT scan
2.place restraints on patient for safety
3. complete a thorough medical, neuro, and psych history
3 or less Correct Answers Capillary refill should take how
many seconds?
, 3 years or younger Correct Answers Pull auricle down and
back for children of what age?
4Os.. orientation to person place time and situation Correct
Answers mental status exam: how to test cognition
9 and 10 Glossopharyngeal and Vagus
To test the gag reflex, touch the sides of the posterior pharynx or
soft palate with a tongue blade. If the reflex is weak or absent,
the patient is in danger of aspirating food or secretions. Correct
Answers what would you test if the patient complained on not
being able to swallow their water?
a Correct Answers A 19 yo has sustained a transaction of C7
in a motor vehicle crash rendering him a quadriplegic. He
describes his pain as burning, sharp, and shooting. what type of
pain is this patient describing?
a. neuropathic pain
b. visceral pain
c. nociceptive pain
d. eudynic pain
A Correct Answers A nurse is caring for a client who is 1 day
postoperative following gynecologic surgery and reports
incisional pain. Which of the following actions should the nurse
take 1st?
a. Ask the client to rate her pain on a scale of 1 to 10
B. Determining when the client last received pain medication
a Correct Answers A patient's eyes jerk while the patient looks
to the left. The nurse will record this finding as
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