Cox_Neuro Part 2

Which statement is true regarding Sjögren's syndrome? Sjögren's syndrome increases lacrimation. Sjögren's syndrome increases body secretions. Sjögren's syndrome decreases the risk for infection. Sjögren's syndrome decreases the digestion of carbohydrates.

Sjogren's syndrom decreases the digestion of carbohydrates Sjögren's syndrome decreases the digestion of carbohydrates because of insufficient secretion of saliva. Sjögren's syndrome decreases lacrimation. Sjögren's syndrome also decreases body secretions and saliva, therefore increasing the risk of infection.

A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure? Calices Glomerulus Macula densa Juxtaglomerular cells

Macula densa The macula densa, a part of the distal convoluted tubule, consists of cells that sense changes in the volume and pressure of blood. Calices are cup-like structures, present at the end of each papilla that collect urine. The glomerulus is the initial part of the nephron, which filters blood to make urine. Juxtaglomerular cells secrete renin. Renin is produced when sensing cells in the macula densa sense changes in blood volume and pressure.

Which complication may be caused by sepsis in burns? Diarrhea Constipation Paralytic ileus Curling's ulcer

Paralytic ileus Paralytic ileus, or hypoactive bowel, is a complication caused by sepsis in clients with burns. Diarrhea can be caused by the use of enteral feedings or antibiotics. Constipation can occur as a side effect of opioid analgesics, decreased mobility, and a low-fiber diet. Curling's ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions. It is caused by a generalized stress response to decreased blood flow to the gastrointestinal tract in clients with burns.

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. Select all that apply Rye Oats Rice Corn Wheat

Rye Oats Wheat Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided.

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? Increased appetite Clubbing of the nail beds Hypertension Weight gain

Weight gain The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.

Non-weight bearing with crutches has been prescribed for a client with a leg injury. The nurse provides teaching before ambulation is begun. To facilitate walking with crutches, what is the most important activity the nurse should teach the client? Sit up in a chair to help strengthen back muscles. Keep the unaffected leg in extension and abduction. Exercise the triceps, finger flexors, and elbow extensors. Use a trapeze frequently to strengthen the biceps muscles.

Exercise the triceps, finger flexors, and elbow extensors The triceps, finger flexors, and elbow extensors are used in crutch walking and therefore need strengthening. Although back muscles keep the person erect, the most important muscles for walking with crutches are the triceps, elbow extensors, finger flexors, and the muscles in the unaffected leg. Keeping the unaffected leg in extension and abduction will do nothing to promote crutch walking. A pushing, not a pulling, motion is used with crutches; the triceps, not the biceps, are used.

A nurse is evaluating the results of treatment with erythropoietin. Which assessment finding indicates an improvement in the underlying condition being treated? 2+ pedal pulses Decreased pallor Decreased jaundice 2+ deep tendon reflexes

Decreased pallor Erythropoietin stimulates red blood cell production, thereby decreasing the pallor that accompanies anemia. It would not have a role in alleviating jaundice. It would not have an appreciable effect on pulses or deep tendon reflexes.

A home care nurse is visiting a client who had a below-the-knee amputation. Which client statement indicates to the nurse that further teaching is needed? "At night, I sleep with a pillow under my knees." "When I sit in a chair, I put my legs out straight on an ottoman." "I apply a firm, even bandage around the end of my affected leg every day." "I press the end of my affected leg against a soft surface several times during the day."

"At night, I sleep with a pillow under my knees." A pillow may promote a flexion contracture of the hip and knee and may interfere with use of a prosthesis and ambulation. The response "When I sit in a chair, I put my legs out straight on an ottoman" expresses an action that prevents pooling of blood and edema in the extremities. The response "I apply a firm, even bandage around the end of my affected leg every day" explains an activity that prevents edema and promotes residual limb shrinkage. Pressing the end of the affected leg against a soft surface several times during the day prepares the residual limb for weight-bearing and for use of a prosthesis.

Which structure protects a client's internal organs, supports blood cell production, and stores minerals? Joints Bones Muscles Cartilages

Bones Bones are the framework of the body; they support and protect internal organs. They also help in stem cell production from bone marrow, and they store minerals. Joints (articulations) help to articulate the bones. Muscles are the bundles of fibrous tissue that contract to produce movement and maintain body posture. Cartilage is a hyaline, elastic, and fibrous tissue that often functions as a shock absorber.

Which drug can cause chemical burns? Anthralin Prednisone Tazarotene Calcipotriene Confident

Anthralin Anthralin is a strong irritant that has an action similar to tar. So this drug can cause chemical burns with topical use. Prednisone is a corticosteroid applied topically to treat psoriasis. Tazarotene and calcipotriene are teratogenic (cause birth defects).

Which joint permits movement in any direction? Pivot joint Hinge joint Biaxial joint Ball-and-socket joint

Ball and socket joint Ball-and-socket joints permit movement in any direction. Pivot joints permit rotation. Hinge joints allow motion in one plane. Biaxial joints permit gliding movement.

A nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the midabdomen, what should the nurse expect to hear? Tympany Borborygmi Abdominal bruit Pleural friction rub

Borborygmi Borborygmi are rapid, high-pitched bowel sounds that are indicative of the hyperperistalsis that occurs behind an intestinal obstruction. Tympany is not auscultated but percussed, and it is described as high pitched or musical because of the presence of gas. An aortic bruit is auscultated above the umbilicus; a renal bruit is heard laterally above the umbilicus. Neither bruit can be auscultated at the midabdomen, and neither is related to an intestinal obstruction. A pleural friction rub is heard in the chest; it is associated with inflamed lung pleura.

For which illness should airborne precautions be implemented? Influenza Chickenpox Pneumonia Respiratory syncytial virus

Chickenpox Chickenpox is known or suspected to be transmitted by air. Diseases that are known or suspected to be transmitted by droplet include influenza and pneumonia. A disease that is known or suspected to be transmitted by direct contact is respiratory syncytial virus.

A client with Hodgkin disease is placed on an ABVD combination chemotherapy regimen. Because doxorubicin is part of this therapy, what education will the nurse provide about this drug? Cease taking any medication that contains vitamin D. Keep the doxorubicin in a dark place protected from light. Expect urine to turn red for a few days after taking this drug. Take the doxorubicin on an empty stomach with large amounts of fluids.

Expect urine to turn red for a few days after taking this drug Doxorubicin causes the urine to turn red for a few days; the client should be informed of this expectation so as not to become alarmed when it occurs. Discontinuing the intake of vitamin D is true for plicamycin, not the drugs in this protocol. It is unnecessary to keep doxorubicin in a dark area, protected from light. Doxorubicin is not given orally, only via the intravenous route.

A client with jaundice associated with hepatitis expresses concern over the change in skin color. What does the nurse explain is the cause of this color change? Stimulation of the liver to produce an excess quantity of bile pigments Inability of the liver to remove normal amounts of bilirubin from the blood Increased destruction of red blood cells during the acute phase of the disease Decreased prothrombin levels, leading to multiple sites of intradermal bleeding

Inability of the liver to remove normal amounts of bilirubin from the blood Damage to liver cells affects the ability to facilitate removal of bilirubin from the blood, with resulting deposition in the skin and sclera. With hepatitis, the liver does not secrete excess bile. Destruction of red blood cells does not increase in hepatitis. Decreased prothrombin levels cause spontaneous bleeding, not jaundice.

Which description describes a coalesced type of skin lesion configuration? Lesions are well defined with sharp borders. Lesions merge together and appear confluent. Lesions are ringlike around flat centers of skin. Lesions have wavy borders that resemble a snake.

Lesions merge together and appear confluent Coalesced skin lesions merge with one another and appear confluent. Circumscribed skin lesions are well defined with sharp borders. Annular skin lesions are ringlike with raised borders around flat centers of the normal skin. Lesions with wavy borders that resemble a snake are described as serpiginous.

A client with malignant hot nodules of the thyroid gland has a thyroidectomy. What is the nurse's priority action immediately postoperative? Check the neck dressing and behind neck for excessive bleeding. Monitor the trachea for deviation to the right or left. Assess the client's level of discomfort and medicate as prescribed. Encourage coughing and deep breathing to prevent atelectasis.

Monitor the trachea for deviation to the right or left A deviated trachea is an imminent sign of airway compromise which requires immediate intervention. The client is at high risk for bleeding within the first 24 hours postoperative. Bleeding can accumulate at the incision site as well as in the neck causing tracheal compression with swelling that may compromise the client's ability to breath. Checking for bleeding may alert the nurse of an increasing risk of airway compromise. Pain management and breathing exercises are standard postoperative interventions.

After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for what treatment? Monthly injections of cyanocobalamin Regular daily use of a stool softener Weekly injections of iron dextran Daily replacement therapy of pancreatic enzymes

Monthly injections of cyanocobalamin Intrinsic factor is lost with removal of the stomach, and cyanocobalamin is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life. Adequate diet, fluid intake, and exercise should prevent constipation. Weekly injections of iron dextran are not considered routine. Daily replacement therapy of pancreatic enzymes does not affect pancreatic enzymes.

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply. Select all that apply Oliguria Lethargy Irritability Hypotension Slurred speech

Oliguria Irritability Hypotension Decreased blood flow to the kidneys leads to oliguria or anuria. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. There are various changes in sensorium, but slurred speech is not a manifestation of shock.

A nurse is caring for a client with a below-the-knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis? Abduct the residual limb when ambulating. Dangle the residual limb off the bed frequently. Soak the residual limb in warm water twice a day. Press the end of the residual limb against a pillow periodically.

Press the end of the residual limb against a pillow periodically The client usually is instructed to press the end of the residual limb against a pillow to toughen the limb for weight bearing; this process is begun by pushing the residual limb against increasingly harder surfaces. Abduction of the residual limb does not maintain functional alignment and should be avoided; it does not prepare the end of the residual limb for a prosthesis. Dangling the residual limb does not help prepare it for a prosthesis and may impede venous return, which prolongs healing. Soaking the residual limb in warm water twice a day may macerate the residual limb and hinder the use of a prosthesis.

The nurse encourages a client with Raynaud disease to stop smoking. Which primary goal is the nurse trying to achieve? Prevent pain and tingling Prevent cyanosis and necrosis Prevent peripheral vasoconstriction Prevent excessive blood oxygen content

Prevent peripheral vasoconstriction Nicotine causes spasms and constriction of the smooth muscles of the arterial vasculature, compromising blood flow to the distal extremities. Nicotine does not directly cause pain and tingling, although these may occur as consequences of nicotine-induced vasoconstriction. Vasoconstriction from nicotine will not result in such severe effects as cyanosis and necrosis. Smoking increases the carboxyhemoglobin level in the blood; carbon monoxide combines with hemoglobin and occupies the sites on the hemoglobin molecule that bind with oxygen, thus decreasing oxygen content.

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? Urinary output Sensation to touch Neurologic status Respiratory exchange

Respiratory exchange The respiratory center in the medulla oblongata can be affected with acute Guillain-Barré syndrome because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurologic status are important, none of them are the priority.

A client is diagnosed as having invasive cancer of the bladder, and brachytherapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of this therapy? Decrease in urine output Increase in pulse strength Shrinkage of the tumor on scanning Increase in the quantity of white blood cells (WBCs)

Shrinkage of the tumor on scanning Brachytherapy, in which isotope seeds are implanted in the tumor, interferes with cell multiplication, which should control the growth and metastasis of cancerous tumors. Radiation affects healthy as well as abnormal cells; urinary output will increase with successful therapy. With brachytherapy of the bladder, increase in pulse strength is not a sign of success. Bone marrow sites may be affected by radiation, resulting in a reduction of WBCs.

When providing discharge teaching to a client who had a total hip replacement, what should the nurse instruct the client to avoid? Climbing stairs Stretching exercises Sitting in a low chair Lying prone for more than 15 minutes

Sitting in a low chair Excessive flexion of the hip can cause dislocation of the femoral head. Climbing stairs should not cause undue strain on the operative site. Stretching exercises should be encouraged as long as no extremes of position are implemented. The client is permitted to lie prone for more than 15 minutes; lying prone should be encouraged because it prevents hip flexion contractures.

A client with a history of a pulmonary embolus is to receive 3 mg of warfarin daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? Poached eggs Spinach salad Sweet potatoes Cheese sandwich

Spinach salad Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet.

The nurse is caring for a client with a possible pulmonary embolism (PE). Which diagnostic test should the nurse initially anticipate will be prescribed for this client because it is the evidence-based gold standard for a PE diagnosis? Spiral (helical) computed tomographic angiography (CTA) D-dimer and arterial blood gas (ABG) laboratory tests Ventilation-perfusion (V/Q) scan Pulmonary angiography

Spiral (helical) computed tomographic angiography (CTA) A spiral (helical) computed tomographic angiography (CTA) is considered the gold standard for a pulmonary embolism (PE) medical diagnosis. The spiral CTA also has the added advantage of diagnosing other pulmonary abnormalities. A pulmonary angiography is still used as a PE diagnostic test, usually if the client also has coronary disease and invasive treatment (i.e., angioplasty) may become necessary; however, it is no longer the gold standard because it is expensive and invasive, and the spiral CTA has excellent accuracy and better accessibility. Ventilation/perfusion (V/Q) scans are currently used only in certain circumstances such as when the client has contrast dye allergy. D-dimer and arterial blood gas (ABG) laboratory tests are typically prescribed for a client with a possible PE; however, these tests are not specific or sensitive enough to be used alone to make the PE diagnosis. An ABG is used to evaluate the client's oxygenation status during medical diagnosis and treatment to determine if additional emergency treatment is needed, such as intubation and mechanical ventilation. A D-dimer simply reveals the presence or absence of fibrin split products which occur when a blood clot degrades or breaks down; however, about half of clients with a PE still test negative (a normal result) and several other conditions can produce a positive D-dimer result.

A client is admitted to the emergency department with head and chest injuries sustained in a motor vehicle accident. What clinical findings indicate that the client is responding to medical intervention and is ready to be transferred from the emergency department to a critical care unit? Stable vital signs and pain Pale and alert but restless Increasing temperature and apprehension Fluctuating vital signs and drowsy but easily roused

Stable vital signs and pain Stable vital signs are the major indicators that transfer will not jeopardize the client's condition. Although complaints of pain are a concern, they do not place the client in physiological jeopardy. Restlessness and pallor may be early signs of shock; the client needs further assessment. An increasing temperature is a sign of increasing intracranial pressure; the client should not be transferred at this time. The vital signs are not stabilized; therefore transfer at this time is contraindicated.

A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify? Support systems that can assist the client at home Potential nursing homes in which the client can recuperate Agencies that can help the client regain activities of daily living Ways that the client can develop relationships with neighbors

Support systems that can assist the client at home The rehabilitative phase requires a balance between activity and rest; supportive individuals are needed to perform more strenuous household tasks and to provide emotional support. A client with mild heart failure does not need inpatient care. A support system should be identified before considering community agencies. More information is needed before encouraging the development of relationships with neighbors.

The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings? Refer the client to a nutritionist after providing health teaching about a low-sodium diet. Place the client in a recumbent position and call the paramedics for transport to the hospital. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible. According to the United States Department of Health and Human Services (Canada: Canadian Heart and Lung Association), both of these readings indicate hypertension and thus require further evaluation by a healthcare provider; having a baseline for both arms can assist the healthcare provider with the medical diagnosis. Teaching about a low-sodium diet is an inadequate intervention. An appointment with a healthcare provider, not a nutritionist, should be scheduled as soon as possible. There are insufficient data to support this emergency intervention (calling the paramedics). The client's elevated blood pressure needs to be evaluated by a healthcare provider and then medical therapy implemented. Although emotional stress can precipitate hypertension, physical causes should be ruled out first.

Why is Phalen's test performed in a client? To diagnose atrophy To diagnose bone tumor To detect rotator cuff injuries To detect carpal tunnel syndrome

To detect carpal tunnel syndrome Phalen's test is used to detect carpal tunnel syndrome. A muscle biopsy is done for the diagnosis of atrophy. A computed tomography scan is done to diagnose a bone tumor. The drop arm test is performed to detect rotator cuff injuries.