Adults II Exam #2 Pre-Test

Which of the following is the initial diagnostic in suspected stroke?

Non-Contrast CT

A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse explain the pathophysiology of this client's health problem?

"The enzymes that your pancreas produces have damaged the pancreas itself."

Which of the following is a cause of a calcium renal stone?

Excessive intake of vitamin D

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Semi-Fowlers

Which is a clinical manifestation of cholelithiasis?

Clay colored stools

The nurse is caring for a postoperative client who has a Kock pouch. Nursing assessment findings reveal abdominal pain, absence of bowel sounds, fever, tachycardia, and tachypnea. The nurse suspects which of the following?

Peritonitis

A client with a history of constipation is instructed to consume a high fiber diet. Which statement by the client about an appropriate food choice indicates the need for additional teaching?

White Bread

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin Sodium

A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?

Initiate Isolation Precautions

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?

Insertion of a NG tube

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time

4:00pmm

After assessing a client with peritonitis, how would the nurse most likely document the client's bowel sounds?

Absent

A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis?

Acute Pain

What is the most common cause of small-bowel obstruction?

Adhesions

A client is suspected to have bacterial meningitis. What is the priority nursing intervention?

Administer Prescribed ABX

A client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery?

Bruit

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first?

Check the client's indwelling urinary catheter for kinks to ensure patency.

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?

Fever and Change in Urine Clarity

The nurse advises the patient with chronic pyelonephritis that he should:

Increase fluids to 3 to 4 L/24 hours to dilute the urine.

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury?

Pad the side rails of the clients bed.

A nurse is caring for a client admitted with acute pancreatitis. Which nursing action is most appropriate for a client with this diagnosis?

Withholding all oral intake, as ordered, to decrease pancreatic secretions

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

A client has had a laparoscopic cholecystectomy. The client is now reporting right shoulder pain. What should the nurse suggest to relieve the pain?

Application of heat 15 to 20 minutes each hour

A community health nurse is caring for a client whose multiple health problems include chronic pancreatitis. During the most recent home visit, the nurse learns that the client is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurse's most appropriate action?

Arrange for the client to be transported to the hospital.

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client?

Assisting the client to turn, cough, and deep breathe every 2 hours

Which of the following, if left untreated, can lead to an ischemic stroke?

Atrial Fibrilation

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication?

Bleeding

A nurse is caring for a patient who is exhibiting signs and symptoms of autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?

Bradycardia, and HyperTension

Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?

Brudzinski sign

A nurse is conducting a health history on a patient who is seeing her health care provider for symptoms consistent with a UTI. The nurse understands that the most common route of infection is which of the following?

By ascending infection (transurethral)

The nurse is caring for a client with a biliary disorder who has an elevated amylase level. If this elevation correlates to dysfunction, which body process does the nurse recognize may be impaired?

Carbohydrate Digestion

Which foods should be avoided following acute gallbladder inflammation?

Cheese - Fatty foods

Which term most precisely refers to the incision of the common bile duct for removal of stones?

Choledocholithotomy

Which insult or abnormality can cause an ischemic stroke?

Cocaine use

The nurse is encouraging the client with recurrent urinary tract infections to increase fluid intake to 8 large glasses of fluids daily. Which beverage would the nurse discourage for this client?

Coffee in the morning

A patient is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to scheduling?

Colonoscopy

A client who is at high-risk for a cerebrovascular accident has medication ordered to lower their cholesterol and to prophylactically anticoagulate them. What specific agent might be diagnosed for this client?

Daily Aspirin

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

Decerebrate

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply

Decreased glucose, increased protein, and increased WBCs

A nurse who works in a clinic sees many patients with a variety of medical conditions. The nurse understands that a risk factor for UTIs is which of the following?

Diabetes Mellitus

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?

Establishing eye contact

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what?

Evidence of hemorrhagic stroke

A client is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication?

Fever, increased heart rate and decreased blood pressure

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?

Form words that are understandable or comprehend spoken words

A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse?

Frequent Neuro checks

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply

Hypotension, venous pooling, tachypnea, and hypothermia

A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action?

Immediate Craniotomy

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

Increased urine output

A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population?

Limit the use of indwelling urinary catheters.

The nurse performs a physical examination on a client diagnosed with acute pyelonephritis to assist in determining which of the following?

Location of discomfort

A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods?

Low-fat foods high in proteins and carbohydrates

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?

Maintain Patent Airway

A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes?

Maintaining fluid and electrolyte balance.

A nurse is planning care for a client with acute pancreatitis. Which client outcome does the nurse assign as the highest priority?

Maintaining normal respiratory function

The nurse identifies a potential collaborative problem of electrolyte imbalance for a client with severe acute pancreatitis. Which assessment finding alerts the nurse to an electrolyte imbalance associated with acute pancreatitis?

Muscle Twitching and finger numbness

If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection?

Perform meticulous perineal care daily with soap and water

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties?

Place the client's extremities where the client can see them.

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse?

Place the patient in a sitting position

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action?

Prepare for interventions to increase the client's BP.

A client's large bowel obstruction has failed to resolve spontaneously and the client's worsening condition has warranted admission to the medical unit. Which of the following aspect of nursing care is most appropriate for this client?

Preparing the client for surgical bowel resection

Which reflects basic nursing measures in the care of the client with viral encephalitis?

Providing Comfort Measures

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?

Pulse and blood pressure.

The nurse is reviewing the results of a urinalysis on a client with acute pyelonephritis. Which of the following would the nurse most likely expect to find?

Pyuria

Which condition or laboratory result supports a diagnosis of pyelonephritis?

Pyuria

A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?

Rebound hypotension

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply

Respiratory Irregularities, Slow bounding pulse, widened pulse pressure.

A client who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this client knows to immediately report what assessment finding to the health care provider?

Rigidity of the abdomen

Which nursing diagnosis is appropriate for a client with renal calculi?

Risk for Infection

A 16-year-old client presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis?

Risk for infection related to possible rupture of appendix

The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of:

Serum Lipase

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness

A 37-year-old client presents at the emergency department (ED) reporting nausea and vomiting and severe abdominal pain. The client's abdomen is rigid, and there is bruising to the client's flank. The client's spouse states that the client was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the client for what health problem?

Severe pancreatitis with possible peritonitis

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?

Smoking

What is a modifiable risk factor for TIA and ischemic strokes?

Smoking

A client with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the client's postprocedure care?

Strain the clients urine following the procedure

What symptoms of perforation might the nurse observe in a client with an intestinal obstruction? Select all that apply.

Sudden, sustained abdominal pain, abdominal distention

A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?

TIA - Transient Ischemic Attack

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client?

The client should be approached on the side where visual perception is intact.

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

Use short, simple sentences

The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelithiasis can interfere with the absorption of

Vitamin A

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

Vomits

A client with a neurologic deficit is feeling frustrated because it is very difficult to pronounce words since having a stroke. The client is struggling with:

dysarthria

A nurse is reviewing lab results for a client with an intestinal obstruction, and infection is suspected. What would be an expected finding?

leukocytosis; elevated hematocrit; low sodium, potassium, and chloride

A nurse is providing post procedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:

notify the physician about cloudy or foul-smelling urine.

A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find?

severe abdominal pain with direct palpation or rebound tenderness

A client returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the client for signs and symptoms of what serious potential complication of this surgery?

Bile Duct Injury

A client has a recent diagnosis of chronic pancreatitis and is undergoing diagnostic testing to determine pancreatic islet cell function. The nurse should anticipate what diagnostic test?

Glucose Tolerance Test (GTT)

The nurse is performing an initial assessment on a client admitted with a possible brain abscess. Which of the following would the nurse most likely find?

Headache that is worse in the morning.

A client who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1ºF (38.4ºC). How should the nurse best respond to the client?

Tell the client to report to the ED for further assessment.

The nurse is assessing a patient with appendicitis. The nurse is attempting to elicit a Rovsing's sign. Where should the nurse palpate for this indicator of acute appendicitis?

LLQ - Left Lower Quadrant

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?

"Emotional lability is common after a stroke, and it usually improves with time."