*Elevate Module 5 Q Review Quiz

Which short term goal is most appropriate for a client with depression who is facing long term rehabilitation? 1. Demonstrate increased interest in family visits. 2. Make realistic plans for coping with rehabilitation. 3. Assign meaning to the life events contributing to the depression. 4. Communicate with other clients on the unit about their problems.

1. Correct: A client with depression likes to be alone, so an appropriate goal that can be realistically accomplished in a short time span is to have the client interested in increased family visits. 2. Incorrect: This would be a long term goal. 3. Incorrect: Assigning meaning is a long term goal. Clients who are depressed cannot identify the cause of depression and fix it. 4. Incorrect: This would be avoidance and that is unhealthy coping.

The client is experiencing autonomic dysreflexia. What is the first action by the nurse? 1. Place in high Fowler's position 2. Find and remove the trigger source 3. Notify the primary healthcare provider 4. Check for fecal impaction

1. Correct: This first action provides some immediate relief to decrease the blood pressure while you are preparing for other interventions. This is one thing the nurse can do immediately to help fix the problem. 2. Incorrect: Later you will look for bladder or bowel distention which is a common precipitating cause of autonomic dysreflexia. 3. Incorrect: The primary healthcare provider will be notified after the nurse intervenes quickly with appropriate nursing measures. 4. Incorrect: Sit client up is the priority and then look for causes.

A nurse is assigned to care for a client with bipolar disorder in the manic phase. Which behavior by the client would require immediate intervention by the nurse? 1. Excessive involvement in a pleasurable activity 2. Suggestive, sexual remarks to the staff 3. Impulsive behavior 4. Euphoria with unusual energy 5. Controlled - substance abusive behaviors

3. & 5. Correct: These are a safety threat. The client could endanger self or others with impulsive and possibly reckless behavior. The client may over-use and abuse medications with controlled substance labeling in the manic phase if accessible, so the nurse would need to monitor these closely. 1. Incorrect: This is a common symptom of mania and could be a problem for the client but, is not a safety threat. 2. Incorrect: This would need to be addressed by the staff, but is not a safety threat. 4. Incorrect: Euphoria is a feeling of intense excitement or happiness and is not a threat to the client.

Which interventions should the nurse include in the plan of care for a client following chest tube placement for a spontaneous pneumothorax? 1. Keep the water seal chamber below the client's chest. 2. Tape all connections between the chest tube and drainage system. 3. Strip the tubing when visible clots noted. 4. Empty the collection chamber of drainage every 24 hours. 5. Perform pulmonary assessment every two hours.

1., 2., & 5. Correct: Keeping the water seal chamber below the client's chest will promote gravity drainage and prevent fluid from going back into the pleural space. Securely tape all connections to prevent the tube from becoming disconnected. Pulmonary assessment should be done at least every 2 hours. Document a comprehensive pulmonary assessment including respiratory rate, work of breathing, breath sounds, pulse oximetry. 3. Incorrect: Avoid aggressive chest tube manipulation, including stripping, or milking, as it can cause extreme negative pressure and damage tissue. 4. Incorrect: Empty every 24 hours? Don't empty them; you change them out when they get full.

The nurse is working on interventions for a young family whose child has severe allergies and asthma symptoms. Which interventions would be important to include in the plan? 1. Wash stuffed animals/toys frequently in hot water. 2. Make sure that bathrooms and high humidity areas are properly vented. 3. Limit carpet in the bedrooms. 4. Use humidifiers regularly. 5. Vacuum floors and upholstered furniture regularly.

1., 2., 3. & 5. Correct: The frequent washing in hot water removes dust mites. Adequate venting lessens the likelihood of fungal/mold spores. Carpet harbors dust and other allergens. The floors and upholstered furniture may harbor dust, pollen from clothing, and other irritants. 4. Incorrect: Humid air may contribute to mold or fungal spores in the house. Less humidity is appropriate.

The client's EEG revealed epileptiform abnormalities predictive of seizure activity and was started on valproic acid 500 mg PO twice a day. What nursing interventions should the nurse include in this client's plan of care? 1. Assess for changes in mood. 2. Check for upper stomach pain and jaundice. 3. Monitor ALT and AST. 4. Teach client not to discontinue medication abruptly. 5. Instruct client to take acetaminophen for mild pain.

1., 2., 3., & 4. Correct: Valproic acid may cause agitation, irritability, or other abnormal behavior. Some clients have suicidal thoughts when first taking this medication. Upper stomach pain and jaundice could be signs of liver or pancreas problems. ALT and AST are your liver enzymes and you better be watching those because valproic acid can cause serious, even fatal hepatotoxicity. Clients should never discontinue anti-seizure meds abruptly. 5. Incorrect: False because acetaminophen metabolism occurs primarily in the liver. Let's pick another pain reliever since we know valproic acid can be hepatotoxic.

The client reports intense headaches with increasing pain for the past month. A magnetic resonance imaging (MRI) is prescribed. In reviewing the client's history, which information is of concern to the nurse? 1. Coronary artery stent 2. Cardiac pacemaker 3. Prescribed glimepiride every morning 4. BMI greater than 40 for 10 years. 5. Occupation as full-time welder.

1., 2., 4. & 5. Correct: With a coronary artery stent the magnet in the MRI may exert too much of a pull on the stent and cause damage. If a client with a cardiac pacemaker has an MRI, the pacemaker is turned off and the client could die. BMI greater than 40 constitutes extreme obesity. Extreme obesity, usually over 300 pounds is contraindicated. Magnetic substances in the body may become dislodged by the magnet, so working as a welder involves metal fragments, and must be reviewed. 3. Incorrect: The client does not need to be NPO or have any modifications of their medications, so hypoglycemia is not a concern for MRI.

A client is admitted for management of chronic obstructive pulmonary disease (COPD). What finding would be of concern to the nurse? 1. Pursed lip breathing 2. Productive cough with thick white sputum 3. Ankles with 2+ pitting edema 4. Barrel chest

3. Correct: Swelling in the legs or feet is a serious symptom and should be of concern to the nurse. To make up for the damage to the lungs, the heart must pump harder to get enough oxygen to the rest of the body. Further investigation is needed. 1. Incorrect: Pursed lip breathing helps keep the alveoli open to allow for better oxygen and carbon dioxide exchange. Clients with COPD are taught how to breathe through pursed lips. 2. Incorrect: A chronic, persistent cough is often the first symptom to develop, and may be present every day as the disease progresses. The cough may or may not be productive. If it is productive, white means free of infection, so that is a good thing. 4. Incorrect: As COPD progresses, the anteroposterior diameter of the chest increases. This increase is called a barrel chest and is not of concern to the nurse.

The post-operative craniotomy client's urinary output suddenly increases to 400 mL in 1 hour. Which nursing action takes priority? 1. Check urine for ketones 2. Measure ICP level 3. Obtain blood pressure 4. Monitor CVP

3. Correct: This is the best answer because we are "worried" this client is going into SHOCK. So.....you better be checking a BP. This is a time where checking the BP is appropriate. If we "assume the worst" I better check a blood pressure. It could have dropped out the bottom. 1. Incorrect: Not the priority here. We are worried about shock. 2. Incorrect: We worry about increased ICP, however, an increased UOP indicates possible diabetes insipidus, so shock is likely. 4. Incorrect: If my client is going into shock, the highest priority is to assess the blood pressure. CVP will let us know if the client has FVD, but the BP will let us know if the client is tolerating it.

A nurse is assigned to care for a client with bipolar disorder in the manic phase. Which behavior by the client would require immediate intervention by the nurse? 1. Excessive involvement in a pleasurable activity 2. Suggestive, sexual remarks to the staff 3. Impulsive behavior 4. Euphoria with unusual energy

3. Correct: This is your only safety threat. The client could endanger self or others with impulsive and possibly reckless behavior. 1. Incorrect: This is a common symptom of mania and could be a problem for the client but, is not a safety threat. 2. Incorrect: This would need to be addressed by the staff, but is not a safety threat. 4. Incorrect: Euphoria is a feeling of intense excitement or happiness and is not a threat to the client.

A client with schizophrenic disorder believes that all of their organs have been replaced and is discussing this belief with others. What would be the most appropriate nursing action? 1. Encourage the client to focus on reality-based issues. 2. Allow the client to continue to talk about the delusions. 3. Ask the client to explain the meaning behind what is being said. 4. Ask the client to take a deep breath to relax. 5. Utilize distraction techniques like music or exercise.

1. & 5. Correct: Get them out of the fantasy and into the real world. Using distraction techniques helps to stop the delusion and develop more effective coping strategies. 2. Incorrect: Do not allow client to continue in a fantasy....this is reinforcing it. 3. Incorrect: This is not appropriate as the client is talking about a delusion. 4. Incorrect: This is not the appropriate time for stress reduction techniques. Yes, the client should use stress reduction techniques but not during the auditory delusion.

A primary healthcare provider documents the following Glasgow Coma Scale score in a client's medical record: "GCS 9 = E2 V4 M3 at 0720". What conclusions should a nurse draw from this documentation? Exhibit: Glasgow Coma Scale Eye Opening 4 Spontaneous 3 To speech 2 To pain 1 None Verbal Response 5 Oriented 4 Confused 3 Inappropriate words 2 Incomprehensible 1 None Best Motor Response 6 Obeys commands 5 Localizes to pain 4 Withdraws from pain 3 Abnormal flexion 2 Extension 1 None Interpretation: Severe: 8 or less Moderate: 9 to 12 Mild :13 to 15 1. A moderate head injury has been sustained. 2. The client opens the eyes in response to a pain stimulus. 3. The client's speech is incomprehensible. 4. Abnormal flexion is observed in the client. 5. The GCS assessment was performed at 7:20 am.

1., 2., 4., & 5. Correct: "GCS 9" indicates that the client has sustained a moderate head injury. A score of "E2" indicates that the client opens the eyes only in response to a pain stimulus. A score of "M3" indicates that the client is exhibiting abnormal spastic flexion of the body (decorticate posture) and "0720" indicates that the assessment was conducted at 7:20 am. 3. Incorrect: "V4" indicates that the client is able to speak, but is confused and/or disoriented.

A school nurse is concerned that a teenager may have bulimia. What assessment findings would substantiate this belief? 1. Discolored teeth 2. Calluses on knuckles 3. Underweight 4. Dehydration 5. Chronic sore throat

1., 2., 4., & 5. Correct: Discolored teeth occur from exposure to stomach acid when throwing up. The teeth may look yellow, ragged, or translucent. Calluses or scars on the knuckles or hands from sticking fingers down the throat to induce vomiting. Dehydration can occur from excessive vomiting and laxative or diuretic abuse. Hoarseness and chronic sore throat can occur due to stomach acid getting in the throat when vomiting. 3. Incorrect: The client is not underweight, but has a changing weight. Most are within normal weight range but may become slightly underweight or slightly overweight.

A client arrives in the emergency department with suspected methamphetamine intoxication. The client is extremely agitated with violent outbursts, hypertensive, and tachycardic. What treatment should the nurse anticipate for this client? 1. Droperidol 2. Lorazepam 3. Methylphenidate 4. Dexmethylphenidate 5. Labetalol 6. Nitroprusside

1., 2., 5., & 6 Correct: What cues did you pick up in the stem? This client is agitated, violent, hypertensive and tachycardic. Would the heart tolerate this for a long time period? No! This is a situation that should be managed quickly. So, how can we best manage this client with methamphetamine intoxication? Let's consider the extreme agitation and violent outbursts. What would be effective in reducing these behaviors? You may be thinking of Inapsine (droperidol) as an antiemetic agent, but are you aware that it is used to produce marked tranquilization, sedation, and a reduction in anxiety? In clients with methamphetamine intoxication, droperidol can produce more rapid and significant sedation than Ativan (lorazepam), but both droperidol and lorazepam can be useful in these clients to not only reduce the agitation and produce sedation, but they can also help reduce the pulse and systolic blood pressure. If the hypertension and tachycardia continues despite the use of droperidol and/or lorazepam, the client may be given a beta-blocker and vasodilator to manage these symptoms. Labetalol is the preferred beta-blocker because of its combined anti-alpha-adrenergic and anti-beta-adrenergic effects. Vasodilators, such as nitroprusside, may be used to help lower the blood pressure. 3. Incorrect: Ritalin (methylphenidate) is a CNS stimulant. Do we need to cause CNS stimulation in this client? No!! This would be dangerous to give a client who is already extremely agitated, has hypertension and tachycardia, and is at risk of having seizures. 4. Incorrect: Focalin (dexmethylphenidate) is also a CNS stimulant and would not be appropriate treatment for this client with hypertension and tachycardia. We would never want to give the client something that would worsen the symptoms!

The parents of a 2 year old child, diagnosed with autism spectrum disorder (ASD), ask the nurse what led the primary healthcare provider to diagnose this disorder for their child. What behaviors will the nurse indicate as signs of ASD? 1. Delusions 2. Twisting 3. Preoccupation with objects 4. Delayed speech 5. Changes are easily tolerated.

2., 3. & 4. Correct: All are behaviors seen in children with ASD. Additionally, they often do not form interpersonal relationships with others or play well with others. They are usually not socially responsive with eye contact and facial expressions. The language characteristics may be delayed, totally absent, echolalia, unusual vocalizations, immature grammatical structures or idiosyncratic words. Their motor behaviors may include poor coordination, tiptoe walking, peculiar hand movements such as flapping and clapping and stereotypical body movements of rocking, dipping, swaying or spinning. 1. Incorrect: Delusions and hallucinations are not characteristic of ASD. These are seen more in the adult. 5. Incorrect: Changes are met with resistance with ASD. Changes in daily routines or in the child's environment can cause catastrophic reactions.

When providing care for a client with a chest drainage unit (CDU) set at 20 cm. of suction, which nursing actions are correct? 1. Maintain chest drainage system at the client's shoulder during transport. 2. Apply tape to the tubing connection sites. 3. Add sterile water to suction control chamber to achieve 20 cm. 4. Assess respiratory effort every shift. 5. Ensure that tubing is not kinked or looped.

2., 3. & 5. Correct: Never raise the drainage system above the level of the client's chest. All connection sites should be tightly secured. If the water level drops below the prescribed suction, more saline must be added. Tubing must not be kinked or looped. 1. Incorrect: CDU must be kept below the client's chest at all times. 4. Incorrect: Respiratory effort for a client with a CDU must be assessed more often than every shift. This assessment should be done at least every 2 hours.

Which nursing actions should the nurse initiate for a client with signs of increased intracranial pressure (ICP)? 1. Encourage coughing and deep-breathing. 2. Administer corticosteroids. 3. Position client midline with head of bed elevated. 4. Determine ability to swallow prior to administering po fluids. 5. Maintain head in neutral alignment.

2., 3., 4., & 5. Correct: Administer corticosteroids to reduce inflammatory response seen in acute brain injury. If I have increased ICP, my reflexes could be suppressed, so check my swallowing. Maintain head in neutral alignment, midline with head of bed elevated to prevent decrease in venous flow which would increase the ICP. 1. Incorrect: Coughing and deep breathing make the ICP go up.

A client admitted to the hospital following a fall has a history of Alzheimer's disease with apraxia. The nurse knows the client will need priority assistance with what activity? 1. Ambulating to the bathroom. 2. Understanding instructions. 3. Using utensils at mealtime. 4. Identifying objects in room

3. Correct: Apraxia is a motor disorder of voluntary movements in which the individual can no longer execute purposeful activity, even though there is adequate mobility, strength, and coordination. This loss of ability to carry out previously learned movements could occur secondary to brain injury or a disease process such as Alzheimer's disease. The client has the ability to pick up utensils but is unable to use them correctly, which may affect the client's nutritional status. 1. Incorrect: Apraxia does not affect the ability to ambulate to the bathroom, although the client may not be able to follow cleanliness procedures once in the bathroom. However, there is another activity is of more concern. 2. Incorrect: The ability to understand is not affected by apraxia, which is a disorder in which the client loses the ability to perform purposeful movement. The client is still able to comprehend instructions at this point. There is another situation in which the client will need assistance. 4. Incorrect: The client is still able to identify objects in the environment; however, the diagnosis of apraxia indicates the client cannot use previously known objects correctly. Because of this situation, there is another area in which assisting the client is of more importance.

The nurse is caring for a client with a closed head injury. Three days after admission, urinary output for 8 hours was 1800 mL. In response to this data, what would be the appropriate nursing action? 1. Hydrate the client with 500 mL of IV fluid in the next hour. 2. Monitor BUN and creatinine. 3. Check urine specific gravity. 4. Recognize this as a side effect of dexamethasone.

3. Correct: For any client with a head injury and abnormally high urinary output, the nurse knows the client is at risk for ADH (anti-diuretic hormone) problems. The pituitary gland is located in the brain. ADH is produced in the pituitary gland. In head injured clients, ADH can get messed up. If the client does not have enough ADH large volumes of water will be lost in the urine. The name of this disease is diabetes insipidus (DI). Large volume losses place the client at risk for shock. The nurse knows to further investigate the problem by checking a urine specific gravity. For clients in DI, the urine specific gravity will be very, very low because they are losing so much water. When you see the letters DI, think of the "D" for diuresis and think SHOCK first. 1. Incorrect: Administration of 500 mL of fluid over one hour is possible if the client were in shock. The stem of the question, however, does not indicate this client is in shock. 2. Incorrect: Monitoring BUN and creatinine does not help identify diabetes insipidus. 4. Incorrect: Decadron can cause fluid retention, not increased urinary output.

The nurse has just received shift report from the off-going nurse. Which client is the priority and should be seen first by the nurse? 1. Client with a chest tube who has bubbling in the suction control chamber of the closed drainage unit (CDU). 2. Client with emphysema with moderate expiratory wheezing. 3. Client post op with a pulse of 120 bpm who the off-going nurse reports as "anxious". 4. Client with pneumonia who reports pain in the chest and a bad cough.

3. Correct: Post op, mild tachycardia and anxious...well that sounds like hypoxia to me. If I have to choose just one client to go see, then I better go see the one that might be experiencing respiratory distress and hypoxia! 1. Incorrect: Is this good bubbling or bad bubbling? Good, right? We expect bubbling in the suction chamber. 2. Incorrect: Wheezing, especially upon exhalation, is commonly seen in clients with emphysema. It does indicate that air is being forced through narrow passages and air trapping is a manifestation of emphysema. However, the client who is anxious and has tachycardia is exhibiting early signs of hypoxia and takes priority. 4. Incorrect: Well, when a client has pneumonia, pain in the chest and a bad cough are expected findings, so this is not the priority over the client with signs of hypoxia.

A client diagnosed with Alzheimer's disease tells the nurse, "I haven't eaten all day. When am I going to eat?" The nurse noted that the client ate 100% of the provided lunch 45 minutes ago. What would be the best way for the nurse to respond? 1. "I'll ask the kitchen if they can send you up another lunch." 2. "What makes you think you didn't eat lunch?" 3. "You ate lunch less than 1 hour ago." 4. "Would you like me to get you some crackers and milk?"

4. Correct: The client believes that he/she has not eaten. Do not argue with the client. Offer the client something to eat. Fix the problem that the client believes he/she has. 1. Incorrect: The client wants to eat but another lunch is not needed since the client ate 100% of the provided lunch, just 45 minutes ago. A snack can be given. 2. Incorrect: Do not argue with the client. This will cause agitation and possible aggression. 3. Incorrect: Again do not argue with the client. The client does not believe he/she has eaten.

A client with a head injury manifests symptoms of increasing intracranial pressure. The primary healthcare provider prescribes mannitol IV. How would the nurse plan to evaluate the effectiveness of this medication? 1. Monitor urine output hourly 2. Take vital signs every 15 minutes 3. Measure head circumference every 8 hours 4. Assess the level of consciousness (LOC) every hour

4. Correct: The stem of the question states the client manifests symptoms of increased ICP. Assessing the LOC is the only answer that assesses for increased ICP. Even if you do not know how mannitol works, the only answer that assesses the client for increased ICP is to assess the LOC. 1. Incorrect: Mannitol causes an osmotic diuresis effect. Urinary output is expected to increase, but this does not assess changes in ICP. Assessing LOC is the only answer that assesses for changes in ICP. 2. Incorrect: Taking frequent vital signs is an answer that sends the message to the NCLEX people that you don't know what to do, so you'll get a set of vital signs. 3. Incorrect: Measuring head circumference is useful if your client is an infant, but frequently assessing the LOC is a more sensitive indicator.

A client has returned to the medical surgical unit from surgery following an emergency appendectomy. The client's spiritual practice involves kneeling multiple times daily for prayer, and the client asks the nurse for assistance to get out of bed to kneel. What statement by the nurse is most appropriate at this time? 1. "You will have to remain in bed for the next 48 hours." 2. "The floor has too much bacteria for you to kneel down." 3. "Aren't there alternatives you can use till you heal more?" 4. "We can help you out of bed whenever you need to pray."

4. Correct: This response by the nurse indicates acknowledgement of the client's spiritual needs as well as specifying a plan to assist in that process. This non-judgmental reply could also provide a positive teaching opportunity regarding surgical recovery, splinting of any incision and appropriate methods for getting out of bed. 1. Incorrect: An appendectomy does not require a client to be bedfast for 48 hours. Remaining in bed would increase the potential for multiple, post-surgical complications, including blood clots or pneumonia. Most clients can be ambulated with assistance within hours of the procedure. 2. Incorrect: While this statement regarding bacteria may be true, it does not justify refusing to allow a client to follow spiritual practices. The nurse should discuss any specific precautions needed with the client. 3. Incorrect: This non-therapeutic communication by the nurse is demanding an explanation of the client. While the question may represent a valid nursing concern, it has not been presented in a positive manner to the client.

The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 44/min, arterial BP 98/50, oxygen saturation 83%, cardiac monitor showing sinus tachycardia at 150 bpm. What action should the nurse take first? 1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 settings to 100%. 3. Hyperventilate client. 4. Auscultate lung sounds.

4. Correct: When an alarm sounds, the first action by the nurse is to assess the client. In this situation, assessment of lung sounds, chest movement, and respiratory effort should indicate which respiratory complication the client may be experiencing. Depending on the assessment findings, the other actions may be necessary. 1. Incorrect: Depending on the assessment findings, the other actions may be necessary. Check the ventilator after checking the client. 2. Incorrect: Depending on the assessment findings, the other actions may be necessary. 3. Incorrect: Depending on the assessment findings, the other actions may be necessary.

A client is admitted to an ED after sustaining a head injury in a motor vehicle crash. The client opens eyes and moans as pressure is applied to the nail bed of fingers and then pulls hand away. Based on this information, what Glasgow Coma Scale score should a nurse document for this client? Exhibit: Glasgow Coma Scale Eye Opening 4 Spontaneous 3 To speech 2 To pain 1 None Verbal Response 5 Oriented 4 Confused 3 Inappropriate words 2 Incomprehensible 1 None Best Motor Response 6 Obeys commands 5 Localizes to pain 4 Withdraws from pain 3 Abnormal flexion 2 Extension 1 None

The nurse should document a Glasgow Coma Scale score of 8 for this client indicating that this client has a severe head injury. The nurse should receive a score of 2 for eye opening in response to pain a score of 2 for an incomprehensible verbal response, and a score of 4 for withdrawing from pain. Generally, head injury is classified as: Severe head injury: GCS score of 8 or less Moderate head injury: GCS score of 9 to 12 Mild head injury: GCS score of 13 to 15