NUR 325: Exam 1
- slightly down and forward as if pointing at nose - correct answer-Insert the speculum of the
otoscope in which direction?
- stuporous: ↓ response to verbal cues or pain
- mute - correct answer-Findings of someone who has altered consciousness?
- awakeness?
- speech?
1 because mild dementia = difficulty learning new skills and forgetfulness - correct answer-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 answer-The speculum of the otoscope must be
inserted ___ cm. Be sure not to do what?
1-2 - correct answer-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 answer-2 main reason to take AD patient to
ambulatory care setting
1. eyelids (no ptosis)
2. pupil constriction
3. ocular movements - correct answer-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 answer-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 answer-Warn MRI patients that (4T):
1. Surgery and treatments (hospitalizations, etc): know details
2. Medications
3. Past health history (osteoporosis, falls, etc) - correct answer-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 answer-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 answer-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 answer-Capillary refill should take how many seconds?
3 years or younger - correct answer-Pull auricle down and back for children of what age?
4Os.. orientation to person place time and situation - correct answer-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 answer-what would you test if the patient complained on not being able to swallow
their water?
a - correct answer-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 answer-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 answer-A patient's eyes jerk while the patient looks to the left. The nurse will
record this finding as
a. nystagmus.
b. CN VI palsy.
c. ophthalmic dyskinesia.
d. oculocephalic response.
a - correct answer-A woman fell while sweeping her driveway and sustained a tissue injury.
She describes her condition as an aching, throbbing back. Which term best describes this
type of pain?
a. nociceptive pain
b. neuropathic pain
c. mixed pain syndrome
d. chronic pain
a - correct answer-The nurse is obtaining a health history of a patient with a fracture. Which
condition poses the most concern related to the musculoskeletal system?
a. Diabetes
b. Hypertension
c. Chronic bronchitis
d. Nephrotic syndrome
ABDEF
not c because level of consciousness remains the same - correct answer-Behavioral
problems occur in most patients with AD. These problems include: Select all that apply.
A. agitation
B. wandering
C. lethargy
D. delusions
E. hallucinations
F. repetitiveness
ABCs --> safety --> maslow - correct answer-what is order of priorities
addiction - correct answer-A primary, chronic, neurobiological disease with genetic,
psychosocial, and environmental factors influencing its development and manifestations
age (65+) - correct answer-What is the greatest risk factor for AD?
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