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Which sign is the cardinal sign of increased intracranial pressure in a patient who has sustained a brain injury?
- A. Pupil changes
- B. Ipsilateral paralysis
- C. Vomiting
- D. Decrease in the level of consciousness
Correct Answer: D
Rationale: Collection of objective data includes a change in level of consciousness. A change in the level of consciousness is the earliest sign of increased intracranial pressure.
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The nurse is aware that the drug t-PA a tissue plasminogen activator, must be given within how many hours of the onset of symptoms to have maximum benefit?
- A. 3 hours
- B. 4 hours
- C. 6 hours
- D. 8 hours
Correct Answer: A
Rationale: t-PA must be given within 3 hours of the onset of symptoms to be beneficial.
Following a myelogram the nurse will include in the postprocedure care observing for which possible complication?
- A. elevation of blood pressure.
- B. urine retention.
- C. Loss of sensation in lower extremities.
- D. slurred speech.
Correct Answer: C
Rationale: Postmyelogram care includes the data collection to ensure there is no leakage of CSF, sensation and strength of the lower extremities, or headache. To avoid a headache, the patient should be flat for a few hours.
The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait, which causes the patient to walk in which manner?
- A. stagger and need support of a walker.
- B. shuffle with arms flexed.
- C. fall over to one side when walking.
- D. take small steps balanced on the toes.
Correct Answer: B
Rationale: The propulsive gait causes the patient to shuffle with his arms flexed and with a loss of postural reflexes.
The nurse explains to a patient and family that the triad of signs of Parkinson disease is: ___, rigidity, and bradykinesia.
Correct Answer: tremor
Rationale: Tremor, rigidity, and bradykinesia are the triad that make up the signs of Parkinson disease.
The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. Which disorder is one example?
- A. Hypotension
- B. Alzheimer's disease
- C. Diabetes
- D. Parkinson disease
Correct Answer: A
Rationale: Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic disturbance, and malnutrition can all be corrected to abolish the dementia.