ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 54 Questions
Question 1 of 5
Which factor is the nurse aware of when assessing a person with a craniocerebral injury?
Correct Answer: C
Rationale: If a patient who has been conscious for several days after head injury loses consciousness or develops neurologic signs and symptoms, a subdural hematoma should be suspected.
Question 2 of 5
Involuntary rhythmic movement of the eyes, with oscillations that may be horizontal, vertical, or mixed movements, is called ___
Correct Answer: nystagmus
Rationale: Nystagmus is a rhythmic movement of the eyes, which may be horizontal, vertical, or mixed in directional movement. The eye movement cannot be controlled by the patient.
Question 3 of 5
Which food should the person who experiences migraine headaches avoid?
Correct Answer: A,B,E
Rationale: Some foods may cause or worsen headaches. Foods that may provoke headaches include vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork.
Question 4 of 5
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?
Correct Answer: B
Rationale: The propulsive gait causes the patient to shuffle with his arms flexed and with a loss of postural reflexes.
Question 5 of 5
A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and 'goose flesh.' Which action will be the initial nursing intervention based on these signs?
Correct Answer: D
Rationale: These are indicators of autonomic dysreflexia or hyperreflexia. It is a medical emergency. The patient should be placed in an upright position to decrease blood pressure and the blood pressure should be checked. Assessments for impaction, full bladder, or a urine infection can help to evaluate this condition.