Exam 2 NRS 3025

A patient has a C4 spinal cord injury. What assessment does the nurse prioritize? a. blood pressure and pulse b. heart sounds c. work of breathing and respiratory rate d. bowel sounds

work of breathing and respiratory rate

A patient on the neuro trauma unit begins to show early signs of increased ICP. What is the nurse's first action? •A. administer mannitol •B. Encourage the patient to cough and deep breath •C. Instruct the patient to bear down as if having a bowel movement •D. Elevate the head of the bed to 40 degrees.

•D. Elevate the head of the bed to 40 degrees. •Rationale: the first action is to elevate the head of the bed to immediately reduce pressure in the brain. A might be done, but it won't be first. B and C would increase the ICP.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? 1) Provide client supervision. 2) Limit client physical activity. 3) Speak loudly to the client. 4) Leave the television on continuously.

1) Provide client supervision. -Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment.

Which is the priority finding in a patient with a recent head injury? a. Decreased in GCS by 3 points b. reports of a 2/10 headache c. constipation and hypoactive bowel sounds d. knowledge deficit regarding discharge medications

Decreased in GCS by 3 points

A patient on the neuro trauma unit begins to show early signs of increased ICP. What is the nurse's first action? a. administer mannitol b. Encourage the pt to cough and deep breath c. Instruct the pt to bear down as if having a BM d. Elevate the HOB 40 degrees

Elevate the HOB 40 degrees

Pancreatitis interventions include (select any that apply): a. NPO b. pain medications c. Encouraging high protein meals d. frequent ambulation

NPO pain medications

A patient with a duodenal ulcer will most likely experience pain that occurs: a. just before eating. b. about 90 minutes to 3 hours after eating. c. about 30-60 minutes after eating. d. upon waking in the morning.

about 90 minutes to 3 hours after eating The pain with a duodenal ulcer occurs couple/few hours after eating. It is a gastric ulcer that occurs shortly after eating.

Interventions for a pt w/ a h/o tonic-clonic siezures? (Select any correct answer) a. Provide a suction setup at the bedside b. Elevate the side rails near the head when the pt is in bed. c. Place the bed in the lowest position. d. Keep an oxygen setup at the bedside.

all are correct

A pt w/ a-fibrillation suddenly develops left sided weakness, slurred speech, and dysphagia. Which intervention? a. IV lorazepam b. Warfarin c. Alteplase d. Carbidopa-levodopa

alteplase

A nurse is providing teaching for a patient with GERD. Which should the nurse tell the patient to avoid? a. chocolate b. skim milk c. apples d. oatmeal

chocolate foods low in fat (skim milk, oatmeal, apples) increase pressure on the lower esophageal sphincter and reduce sx of GERD; fatty, fried foods, chocolate, caffeine, and carbonated drinks reduce pressure on the LES.

True or false: Brain tumor classification is based on location and histologic characteristics.

True

An RN is talking w/ pt w/ cholelithiasis & will have an oral cholangiogram. Which statement indicates pt understands? a. "soon those shock waves will get rid of my call stones." b. "They'll put medicaiton into my gallbladder to dissolve the stones." c. "I'll have a camera put down my throat so they can see my gallbladder." d. "They are going to examine my gallbladder and ducts."

"They are going to examine my gallbladder and ducts." With oral cholangiography, the client receives an iodide-containing contrast agent 10 to 12 hr before the procedure. Then, the examiner can evaluate the gallbladder for filling, contracting, and emptying and can also see the gallstones on the x-rays. A is lithotripsy, B is ERCP, and C is no medication is given to dissolve stones.

Pt w/ new Crohn's asks the RN if he will have to come to the hospital for transfusions like friend w/ UC. Best response? a. "I don't anticipate you'll need blood at this point in your disease." b. "It all depends on which immunotherapy you decide to be treated with." c. "UC causes more bleeding than Crohn's, so you have less risk of GI bleeding" d. "You are at a high risk, but we can teach you best ways to prevent bleeds."

"UC causes more bleeding than Crohn's, so you have less risk of GI bleeding" B is accurate and therapeutic. A doesn't really address his fears. C. is not true and also doesn't answer his question. D. is not accurate.

A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? 1) "An MRI scan is not distorted by movement, so you do not have to lie still." 2) "An MRI scan is a short procedure and should take no longer than 30 minutes." 3) "The MRI contrast dye contains iodine and can cause your skin to itch." 4) "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."

4) "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner." -The nurse should instruct the client that many clients report being disconcerted by the loud thumping and humming noises produced by the scanner, and for that reason, earplugs are offered to reduce the discomfort.

Which patient is at highest risk for a functional bowel obstruction? a. A patient with a hernia b. A patient recovering from surgery taking hydromorphone for pain c. A patient with radiation to the prostate and local skin irritation d. A patient with chronic renal insufficiency and high potassium

A patient recovering from surgery taking hydromorphone for pain the recent surgery and opioids both put the patient at risk for obstruction.

A patient with hepatic encephalopathy develops diarrhea. The nurse interprets this as: a. A side effect of the necessary treatment for encephalopathy. b. A sign of worsening liver function. c. Likely c-diff infection. d. An induction that the total bilirubin levels are decreasing.

A side effect of the necessary treatment for encephalopathy. lactulose is the treatment for encephalopathy. It decreases the ammonia level but also causes diarrhea. It should NOT be stopped just because the patient develops diarrhea.

A client is scheduled for an MRI. The client asks what to expect. What should RN say? a. An MRI scan is not distorted by movement, so you can move b. An MRI is a short procedure & should take about 30 min c. MRI contrast contains iodine and can cause your skin to itch d. An MRI is very noisy, but you may wear earplugs

An MRI is very noisy, but you may wear earplugs

Which action should the RN take prior to giving PO meds to a pt with Parkinsons? a. Have the client empty his bladder. b. Put up the side rails on the client's bed. c. Ask the client to take a few sips of water. d. Place the client in low Fowler's position.

Ask the client to take a few sips of water. -Clients who have myasthenia gravis have weakness of the muscles of the face and throat, which increases the risk for aspiration. The nurse should check the client's ability to swallow before administering oral medication.

A pt is very anxious about feeling pain during an upcoming colonoscopy. Which response by the nurse is appropriate? a. "Don't worry; most pts dislike the prep more than the actual procedure." b. Before the exam your provider will give you a sedative to make you sleepy. c. I know you're anxious, but this is recommended for people your age d. After you sign the consent form we can talk more about this

Before the exam your provider will give you a sedative to make you sleepy. This is a therapeutic response that provides accurate information that can lead to further discussion.

A pt with acute diverticulitis has an NGT draining green liquid bile. Which action should the nurse take? a. Document the findings as normal b. Assess the pt's bowel sounds c. Determine the pt's last BM d. Insert the NGT at least 2 more inches

Document the findings as normal green bile/GI acid should be draining, so the action is to document, B & C. Neither would affect the NGT, D. the drainage indicates it's correctly in the stomach

A patient with cirrhosis develops encephalopathy. The nurse should prioritize: a. Establishing fall precautions and safety measures. b. Encouraging frequent ambulation around the unit. c. Reinforcing the importance of using an incentive spirometer. d. Teaching the patient when she's alone to minimize distractions.

Establishing fall precautions and safety measures.

Which dietary selection is most appropriate for a patient with diverticulitis? a. Turkey sandwich and celery sticks b. Grilled chicken breast and white rice c. Pork tenderloin and green peas d. Sliced ham with a spinach salad

Grilled chicken breast and white rice the correct answer is low fiber, which is recommended during inflammation - in the presence of diverticulosis, a high-fiber diet is recommended.

A pt w/ MS reports of diplopia, dysmetria, & sensory change. What is appropriate d/c teaching? a. Wear an eye patch on the right eye at all times b. Plan to relax in a hot tub spa each day c. Engage in a vigorous exercise program d. Implement a schedule to include periods of rest

Implement a schedule to include periods of rest -The nurse should assist the client in developing a schedule that includes periods of exercise followed by periods of rest to maintain muscle strength and coordination.

A patient is one day post operative for a cholecystectomy and reports right shoulder pain. The nurse should: a. Instruct the patient to use an ice pack and start PT as prescribed. b. Instruct the patient to report to the emergency department immediately. c. Ask the patient if he did anything to injury his shoulder or arm? d. Instruct the patient to walk around and use a heat pack.

Instruct the patient to walk around and use a heat pack. Right shoulder pain is common after a cholecystectomy. It is often from the gas instilled during surgery. Heat and ambulation help dissipate the gas and hence the pain.

A patient with Ms is experiencing an exacerbation of symptoms. What is the most likely cause of the exacerbation? a. The change in seasons b. New responsibilities and tensions at work c. The time of day d. Triggers for exacerbations are unknown

New responsibilities and tensions at work stress is a major trigger for exacerbations of MS.

A pt w/ ALS says, "Sometimes I feel so frustrated. I can't do anything w/o help!" Nursing dx? a. Anxiety b. Powerlessness c. Ineffective denial d. Risk for disuse syndrome

Powerlessness

When teaching to the family of a pt w/ Parkinson's, what info should the RN include? a. Provide client supervision b. Limit client physical activity c. Speak loudly to the client d. Leave the television on continuously

Provide client supervision

Which is the purpose of the administering an osmotic diuretic IV to a pt with increased ICP? a. Reduce edema of the brain b. Provide fluid hydration c. Increase cell size in the brain d. Expand extracellular fluid volume

Reduce edema of the brain -An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream.

The nurse is admitting a pt with adenocarcinoma of the rectosigmoid colon. Which assessment data support this dx? a. The client reports up to 20 bloody stools per day b. The client complains of RLQ pain c. The client has a feeling of fullness after a heavy meal. d. The client has diarrhea alternating with constipation.

The client has diarrhea alternating with constipation. the correct answer is low fiber, which is recommended during inflammation - in the presence of diverticulosis, a high-fiber diet is recommended.

A pt w/ a brain tumor has a GCS of eye opening=3, verbal = 5, & motor =5. Your conclusion? a. The client can follow simple motor commands b. The client is unable to make vocal sound c. The client is unconscious d. The client opens his eyes when spoken to

The client opens his eyes when spoken to -A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.

Why is a CT necessary when stroke is suspected? a. To plan the staffing levels on the unit. b. To estimate the date to start rehabilitation. c. To determinate the dose of thrombotic therapy. d. To differentiate between a hemorrhagic and ischemic stroke.

To differentiate between a hemorrhagic and ischemic stroke. The treatment varies greatly based on what type of stroke it is. Therefore, the CT helps determine the type and ultimately what treatment will be used.

Which is a key difference between dementia and delirium? a. The is always an underlying cause for delirium. b. Dementia is an acute problem, but dementia is not. c. Patients with delirium often experience sundowners. d. Delirium is unavoidable but dementia is not.

The is always an underlying cause for delirium. a UTI, medications, even hospitalization can be the trigger. Either way, the nurse must work to identify the cause so that he or she can work on correcting it. Delirium is acute and avoidable, dementia is less preventable than delirium, and often pts with dementia have sundowners.

Why does the nurse prioritize frequent abdominal assessments for a pt with a small bowel obstruction? a. To know when the diet can be advanced and nutrition can be restored b. To be able to alert the surg. team as soon as signs of complications occur c. To predict what will be removed via the nasogastric tube d. To be prepared to teach the patient when to expect their enema

To be able to alert the surg. team as soon as signs of complications occur The nurse must always be prepared to the possibility of emergent surgery or acute complications that require intervention.

An RN is assessing a pt who has Parkinson's. Which manifestation should the nurse expect? a. Pruritus b. Hypertension c. Bradykinesia d. Xerostomia

bradykinesia -The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.

A pt reports to the ED w/ dizziness that started this AM. Her BP 78/46, HR is 130, hgb is 6.5. The nurse suspects: a. erosive esophagitis b. peritonitis c. acute cholecystitis d. gastrointestinal bleeding

gastrointestinal bleeding These manifestations together suggest a GI bleed. Cholecystitis would cause RUQ pain, peritonitis would be excruciating abdominal pain and signs of infection or shock, erosive esophagitis would cause epigastric / esophageal pain and could cause bleeding, but this is not the priority unless there is specific reason to suspect this is the type of GI bleed. If you do not know what is going on, start broad and narrow it down with your assessment.

A patient with spinal cord injury at T1 develops a HR of 46, BP of 190/94, and is diaphoretic. What is the next action? a. elevate the head of the bead to 35 degrees. b. call the neurosurgeon. c. remind the patient to take deep breaths. d. perform a bladder scan.

perform a bladder scan.

A patient with advanced ALS is admitted with aspiration pneumonia. They should avoid consuming which of these items? a. Tap water b. Sweet potatoes c. Pudding d. These are all good choices

tap water

Brain tumor classification is based on location and histologic characteristics. True False

true

RN is assessing a pt w/ an acoustic neuroma. Which manifestations should the nurse expect? a. Vertigo b. Dysphagia c. Diplopia d. Apraxia

vertigo -The RN should expect a client with an acoustic neuroma, a benign tumor of cranial nerve VIII, to manifest mild to moderate vertigo as time progresses.