AMS test #4 practice quiz

A nurse is planning care for several clients and is considering the clients ' risk for stroke . Which of the following conditions places the client at risk for an ischemic A nurse is planning embolic stroke ?

A client who has chronic atrial fibrillation -a small thrombus might dislodge and migrate to the brain .

A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching?

"I need to catheterize myself twice a day" -In most cases, paralysis from waist down affects bladder and bowel control. Catheterization should be performed every 4 to 6 hr, and as needed. Infrequent emptying of the bladder can result in urinary tract infections.

A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following is an appropriate response by the nurse?

"Incorporate nonverbal cues in the conversation." -The nurse should remind the family to use nonverbal cues to enhance the client's ability to comprehend and use language.

(NGN) (mainly Parkinson's) For each client finding. click to specify if the finding is consistent with Parkinson's disease, stroke, and/or multiple sclerosis. Each finding can support more than one disease process.

-Disorientation is consistent with Parkinson's disease, stroke, and multiple sclerosis. -Shuffling gate is consistent with Parkinson's disease. -Resting tremors are consistent with Parkinson's disease. -Slurred speech is consistent with Parkinson's disease, stroke, and multiple sclerosis. -Facial rigidity is consistent with Parkinson's disease.

(NGN) (mainly stroke) For each client finding. click to specify if the finding is consistent with Parkinson's disease, stroke, and/or multiple sclerosis. Each finding can support more than one disease process.

-Facial symmetry is consistent with stroke. -Hypertension is consistent with stroke. -Cognitive function is consistent with Parkinson's disease, stroke, and multiple sclerosis. -Speech is consistent with Parkinson's disease, stroke, and multiple sclerosis. -Mobility is consistent with Parkinson's disease, stroke, and multiple sclerosis.

A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown? (Select all that apply.)

-Use pillows to keep heels off the bed surface. -Keep environmental humidity less than 30% -Minimize skin exposure to moisture.

A nurse is reinforcing teaching with a client who has Parkinson's disease. The client tells the nurse that he gets nausea when he takes his prescribed levodopa/carbidopa. Which of the following foods should the nurse recommend the client take with the medication?

1 cup (8oz) of applesauce -The client should take levodopa/carbidopa with food to decrease nausea and vomiting but should avoid food high in protein because it interferes with absorption and decreases the therapeutic response. 1 cup of applesauce contains less than one-half a gram of protein.

A nurse is caring for a client who had a stroke and has dysphagia. The nurse should monitor the client for which of the following complications?

Aspiration -Client who have dysphagia are at risk for aspiration pneumonia. The nurse should monitor the client for fever and adventitious breath sounds.

A nurse is assisting with the food tray for a client who is partially blind following a left - sided stroke . Which of the following nursing interventions promotes client independence ?

Describe to the client the location of the food on the tray

A nurse is assisting with the plan of care for a client who has a cerebral aneurysm . The nurse should plan to monitor the client for which of the following early indications of increased intracranial pressure ?

Desorientation to time and place -This finding occurs due to reduced oxygen and glucose in the brain.

A nurse caring for a client who has a spinal cord injury and is at risk for depression . Which of the following findings should the nurse identify as an indication that the client is developing depression?

Difficulty concentrating -Clients who have a spinal cord injury often have an overwhelming sense of loss , and major depression. The client can have feelings of hopelessness, powerlessness , have a decreased ability to perform ADLS, poor problem solving skills impaired cognitive functioning , and difficulty making decisions and concentrating.

A nurse is caring for a client who has increased intracranial pressure . Which of the nursing interventions should the nurse take ?

Elevate the head of the bed 30 degrees -elevating the head of the bed 15 to 30 will reduce intracranial pressure .

(NGN) asks to Select the 3 (but it's 4) findings that require immediate follow - up.

Hourse voice at 1500 Breath sounds at 1800 Drooling at 1800 Temperature at 1800

A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation . Which of the following long - term goals is appropriate with regard to the client's mobility ?

Propel a wheelchair equipped with knobs on the wheels . -A client who has an injury at C8 has full use of the shoulders and arms but will likely experience hand weakness . The addition of knobs on the wheels will help the client use the wheelchair more effectively .

A nurse is contributing to the plan of care for a client who has a spinal cord injury resulting in paraplegia . Which of the following interventions should the nurse include ?

Provide a high protein high - calorie diet -Following injury , the client will have increased caloric needs

A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia . Which of the following actions should the nurse take first ?

Raise the head of the bed . -using the airway breathing circulation approach. Immediately place the client in a sitting position or raise the HOB to a 45 ° angle to lower the client's blood pressure .

A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?

Re-establish communication. -A stroke is an interruption of the blood supply to a part of the brain, resulting in oxygen-deprived brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-hemispheric stroke, the nurse can anticipate that the client will have some degree of aphasia and will require communication-focused nursing interventions and speech therapy to re-establish communication.

A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial Which of the following is an appropriate nursing action ?

Reduce stimuli -reduce stimuli by decreasing the number of visitors, remaining calm, and creating a quiet environment.

A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Remind that the client look for food on the left side of the tray -The action of reminding the client to look for food on the left side of the tray will train the client to scan the tray by moving her head and eyes. This action will help to resolve the problem of homonymous hemianopsia.

A nurse is caring for a client who had a left - sided stroke and is now having difficulty swallowing . For which of the following health care providers should the nurse recommend a referral to assist the client with swallowing ?

Speech therapist

A nurse is contributing to the plan of care of a client who has had a stroke The client is experiencing severe dysphagia with choking and coughing while eating . Which of the following nutritional therapies should the nurse expect to include in the plan of care ?

Supplement via NG tube -NG tube provides enteral nutrition for clients who are at risk for aspiration caused by a diminished gag reflex or difficulty swallowing

A nurse is caring for a client who has global aphasia . Which of the following actions should the nurse take ?

Use the exact same words when repeating statements -The client may have only understood the first half of the sentence the first time and will need to have it repeated to understand fully

A nurse is collecting data from a client who has Parkinson's disease and is experiencing bradykinesia. Which of the following findings should the nurse expect?

sturred speech -The nurse should expect to observe slowed, slurred speech in a client who is experiencing bradykinesia.