Glasgow Coma score (GCS) is made up of 3 component parts and
these are:
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Eye opening
response/motor response/verbal response
Eye opening
response/verbal response/pupil reaction to light
Eye opening
response/motor response/pupil reaction to light
Eye opening
response/limb power/verbal response
Correct answer
Eye opening response/motor
response/verbal response
In the NEWS observation system, what is ACVUP?
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A
replacement for GCS
An
assessment for confusion
Assessment
for the level of consciousness
Correct answer
Assessment for the level of
consciousness
A patient got admitted to hospital with a head injury. Within 15
minutes, GCS was assessed and it was found to be 15. After initial assessment,
a nurse should monitor neurological status every:
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15 minutes
30 minutes
45 minutes
60 minutes
Correct answer
30 minutes
Approximately how long is the spinal cord in an adult?
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30 cm
45 cm
60 cm
120 cm
Patient had undergone post lumbar tap and is exhibiting increase
HR, decrease BP, and alteration in consciousness and dilated pupils. What is
the patient likely experiencing?
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Headache
Shock
Brain
herniation
Hypotension
Correct answer
Brain herniation
Which is not an expected side effect of lumbar tap?
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Headache
Back pain
Swelling
and bruising
Nausea and
vomiting
Correct answer
Nausea and vomiting
A patient was recommended to undergo lumbar puncture. As the
nurse caring for this patient, what should you not expect as its complications:
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Swelling
and bruising
Headache
Back pain
Infection
Correct answer
Infection
How should you position a patient after lumbar puncture?
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Flat on bed
Fowler’s
Semi-fowlers
Side-lying
Correct answer
Flat on bed
Which is not an indication for lumbar tap?
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For patients with increased ICP
For
diagnostic purposes
Introduction
of spinal anaesthesia for surgery
Introduction
of contrast medium
It is unsafe for a spinal tap to be undertaken if the patient:
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Bacterial
meningitis
Papilloedema
Intracranial
mass is suspected
Site skin
infection
All the above
After lumbar puncture, the patient experienced shock. What is
the etiology behind it?
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Increased
ICP
Headache
Side effect
of medications
CSF leakage
Correct answer
CSF leakage
A client immediately following lumbar puncture developed
deterioration of consciousness, bradycardia, increased systolic blood pressure.
What is this normal reaction
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Client has
brain stem herniation
Spinal
headache
Correct answer
Client has brain stem
herniation
A patient just had just undergone lumbar laminectomy, what is
the best nursing intervention?
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Move the
body as a unit
Move one
body part at a time
Move the
head first and the feet last
Never move
the patient at all
Correct answer
Move the body as a unit
Lumbar post op patient moving and handling
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Move patient as a unit
Move
patient close to side rails so he/she could assist herself
Move with
leg raised/flexed
After lumbar laminectomy, which the appropriate method to turn
the patient?
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Patient
holds at the side of the bed, with crossed knees try to turn by own
Head is
raised and knees bent, patient tries to make movement
Patient is
turned as a unit
Correct answer
Patient is turned as a unit
When positioning the supine patient in bed, why should you
ensure the patient is lying centrally in the bed?
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To ensure
spinal and limb alignment
To ensure
patient comfort
To ensure
the airway is patent
To minimize
the risk of injury to the practitioner
Correct answer
To ensure spinal and limb
alignment
In what instances shouldn't you position a patient in a
side-lying position?
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If they are
pregnant
If they
have a spinal fracture
If they
have pressure sores
If they
have lower limb pain
Correct answer
If they have a spinal
fracture
In Spinal cord injury patients, what is the most common cause of
autonomic dysreflexia ( a sudden rise in blood pressure)?
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Bowel
obstruction
Fracture
below the level of the spinal lesion
Pressure
sore
Urinary
obstruction
Correct answer
Urinary obstruction
Patient had CVA and can't speak nor read. What does the loss of
speech mean?
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Dysphagia
Aphasia
Apraxia
Dysphasia
Correct answer
Aphasia
A patient suffered from stroke and is unable to read and write.
This is called
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Aphasia
Dysphagia
Partial
aphasia
Correct answer
Aphasia
Patient had CVA, who will assess swallowing capability?
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Physiotherapy
nurse
Psychotherapy
nurse
Speech and
language therapist
Neurologic
nurse
Correct answer
Speech and language therapist
Mrs Jones has had a cerebral vascular accident, so her left leg
is increased in tone, very stiff and difficult to position comfortably when she
is in bed. What would you do?
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· Give Mrs
Jones analgesia and suggest she sleeps in the chair
· Try to
diminish increased tone by avoiding extra stimulation by ensuring her foot
doesn't come into contact with the end of the bed; supporting, with a pillow,
her left leg in side lying and keeping the knee flexed
· Give Mrs
Jones diazepam and tilt the bed
· Suggest a
warm bath before she lies on the bed Then use pillows to support the stiff limb
Correct answer
Try to diminish increased
tone by avoiding extra stimulation by ensuring her foot doesn't come into
contact with the end of the bed; supporting, with a pillow, her left leg in
side lying and keeping the knee flexed
A patient suffered from CVA and is now affected with dysphagia.
What should not be an intervention to this type of patient?
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· Place the
patient in a sitting position / upright during and after eating
· Water or clear liquids should be given
· Instruct
the patient to use a straw to drink liquids
· Review the
patient’s ability to swallow, and note the extent of facial paralysis
A client with CVA is found to have difficulty in swallowing. Who
do you think should be informed for further assessment?
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Neurological
physiotherapist
Occupatoinal
physiotherapist
Speech and Language Therapist
An adult has experienced a CVA that has resulted in right side
weakness. The nurse is preparing to move the patient right side of the bed so
that he may then be turned to his left side. The nurse knows that an important
principle when moving the patient is.
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To keep the
feet close together
To bend
from waist
To use body weight when moving objects
A twisting
motion will save steps
The prevalence of sudden onset confusion in the hospital
environment is between 20% and 50% (NICE 2010). Certain factors predispose to
or are risk factors includes all of the following, except:
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Infection,
post-anaesthesia and taking high doses of analgesia
Other
serious illnesses such as uncontrollable cardiovascular or respiratory
conditions
English is
not their first language with existing other mental disorder such as dementia
Being
inpatient for a long time with or without family and means of gauging the time
of the day
Correct answer
Being inpatient for a long
time with or without family and means of gauging the time of the day
Patient’s husband died. The brother of the patient saw that she
was upset but mentally and physically well. After a few weeks, the patient
called her brother and said that her husband died yesterday, she verbalized “I
didn’t know he was sick”. She also told her brother that she has been seeing
mice and rats in the house. The patient had difficulty sleeping, had
incontinence and pain in urinating. A community nurse visited the patient. She
observed that the patient is reclusive, passive but pleasant. What could be the
problem?
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Delirium due to UTI
Uncoping
ability because her husband just died
Onset of
Alzheimer’s disease from dementia
Delayed
bereavement due to dementia
An 83-year old lady just lost her husband. Her brother visited
the lady in her house. He observed that the lady is acting okay but it is
obvious that she is depressed. Three weeks after the husband's death, the lady
called her brother crying and was saying that her husband just died. She even
said, "I cant even remember him saying he was sick." When the brother
visited the lady, she was observed to be well physically but was irritable and
claims to have frequent urination at night and she verbalizes that she can see
lots of rats in their kitchen. Based on the manifestations, as a nurse, what
will you consider as a diagnosis to this patient?
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Urinary
tract infection leading to delirium
Delayed
grieving with dementia
Correct answer
Urinary tract infection
leading to delirium
Which is not an appropriate way to care for patients with
Dementia/Alzheimer’s?
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Ensure
people with dementia are excluded from services because of their diagnosis,
age, or any learning disability
Encourage
the use of advocacy services and voluntary support
Allow
people with dementia to convey information in confidence
Identify
and wherever possible accommodate preferences (such as diet, sexuality and
religion)
Correct answer
Ensure people with dementia
are excluded from services because of their diagnosis, age, or any learning
disability
A patient who has had Parkinson’s Disease for 7 years has been
experiencing aphasia. Which health professional should you make a referral to
with regards to his aphasia?
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Occupational
Therapist
Community
Matron
Psychiatrist
Speech and Language Therapist
Positioning and active movement are key in managing the
influence of altered tone and abnormal patterns of movement in the recovery of
motor control in patients with neurological problems. All of the following are
the general principles of care with complex neurological impairments, except:
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· Positioning
is suggested as a strategy to prevent pain and to prevent loss of range of
movement for patients with low tone particularly around the shoulder
· Patients
with little limb function secondary to soft tissue changes and contractures are
at increased risk of hypotonia
· Adaptation
of the mechanical properties of muscle also contributes to increased tone in
patients with hypertonia
· For those
with acute and long-standing neurological issues, principles of moving can be
applied at any time along their treatment trajectory from undertaking
rehabilitation, experiencing deteriorating function or those requiring
palliative management
Correct answer
Patients with little limb
function secondary to soft tissue changes and contractures are at increased
risk of hypotonia
You are caring for a patient who has had a recent head injury
and you have been asked to carry out neurological observations every 15
minutes. You assess and find that his pupils are unequal and one is not
reactive to light. You are no longer able to rouse him. What are your actions?
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· Continue
with your neurological assessment, calculate your Glasgow Coma Scale (GCS) and
document clearly
· This is a
medical emergency Basic airway, breathing and circulation should be attended to
urgently and senior help should be sought
· Refer to
the neurology team
· Break down
the patient's Glasgow Coma Scale as follows: best verbal response V = XX, best
motor response M = XX and eye opening E = XX Use this when you hand over
Correct answer
This is a medical emergency Basic airway, breathing and circulation should be attended to urgently and senior help should be sought
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