Exam 3

A client diagnosed with bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A) Applying a protective eye shield at night B) chewing on the affected side to prevent unilateral neglect C) avoiding the use of analgesics whenever possible D) avoiding brushing the teeth

A

A client presents to the ED with friends who state that the patient intentionally ingested a "bottle of Aleve". Upon arrival, the initial nursing priority would include: A) Assessment of health history including allergies B) Assessment of respiratory status C) Initiation of IV therapy D) Assessment of circulatory status

B

A client with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process? A) Cyclosporine B) Acyclovir C) Cyclobenzaprine D) Ampicillin

B

A nurse caring for a client who experiences debilitating migraine headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache. A) as soon as the pain becomes unbearable B) as soon as the patient senses the onset of symptoms C) 20 to 30 minutes after the onset of symptoms D) when the client senses his symptoms peaking

B

A client with Gillian-Barre' syndrome has experienced a sharp decline their respiratory status/ vital capacity. What is the nurse's most appropriate action? A) Administer bronchodilators as prescribed B) remind the client of the importance of deep breathing and coughing exercises C) prepare to assist with intubation D) administer supplementary oxygen by nasal cannula

C

When caring for a patient who was admitted 24 hours previously with a C4 spinal cord injury, which nursing action has the highest priority? A) Continuous cardiac monitoring for bradycardia B) administration of methylprednisolone Infusion C) assessment of respiratory rate and depth D) application of pneumatic compression devices to both legs

C

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A) Sit with the client for a few minutes B) administer an analgesic C) inform the nurse manager D) call the health care provider immediately

D

A client diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in health status would the nurse attribute to the client's metastatic brain disease? A) Chronic pain B) Respiratory distress C) Fixed pupils D) Personality changes

D

A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? A) Cognitive declines B) Personality changes C) Contractures D) Difficulty in coordination

D

A nurse caring for a client with a spinal cord injury reports a severe headache and is sweating profusely BP 200/110 mmHg, HR 52. Which of the following actions should the RN take first? A) Notify the provider B) Sit the client upright C) Check the foley for blockage D) Administer antihypertensive medication

B

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient, the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A) Epidural hemorrhage B) hypertensive emergency C) spinal shock D) hypovolemia

C

A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic brain injury. The primary care provider calls for a report on the clients. Based on the documentations below how should the nurse respond? TIME 0500 0815 0810 0845 ICP 20 18 18 16 A) The clients ICP has decreased to lower than normal limits B) The clients ICP remains elevated C) The clients ICP is within normal limits D) The clients ICP was elevated but now has returned to normal

B

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? A) To decrease cerebral edema B) To prevent seizure activity that is common following a TIA C) To remove atherosclerotic plaques blocking cerebral flow D) To determine the cause of the TIA

C

A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. Which of the following would the nurse expect the health care team to focus on? A) Physical therapy B) speech therapy C) advanced directives D) surgical intervention

C

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the clients atmosphere more conducive to communication? A) Provide a communication board of commonly used needs and phrases B) Have the client speak to loved ones on the phone daily C) Help the client complete their sentences as needed D) Speak in a loud and deliberate voice to the client

A

A client is admitted reporting a headache. The client is allergic to morphine, iodine, and codeine. Which health-care provider order should the nurse question? A) Schedule for CT scan with contrast in AM B) administer acetaminophen 650 mg PO for headache C) Take clients vital signs per protocol D) provide the client with a low fat, low cholesterol diet

A

A client is being treated in the ED following a terrorist attack period the client is experiencing blurry vision, nausea, vomiting and excessive salvation. The nurse suspects this client has been exposed to what chemical agent? A) Nerve agent B) Pulmonary agent C) Vesicant D) Blood agent

A

A client is brought to the Ed with multiple trauma after a motor vehicle accident (MVA) primary assessment has been completed and any immediate threats to life have been addressed, the nurse and trauma team should take what action? A) Perform a rapid physical assessment B) Perform diagnostic imaging C) Initiate health education D) Obtain a urine sample

A

A client presents to the ED with suspected alcohol intoxication. The ED nurse is aware to assess for conditions that may mimic acute alcohol intoxication and should perform with action? A) Check the patient's blood glucose level B) Perform suicide screen C) Obtain vital signs D) Leave the patient in a room until the patient "sobers up"

A

A client who had a craniotomy is receiving mannitol (Osmitrol) IV to decrease intracranial pressure. Which diagnostic laboratory value should be monitored while the client is receiving this medication? A) Serum osmolarity B) white blood cell (WBC) count C) Serum cholesterol D) erythrocyte sedimentation rate (ESR)

A

A client who suffered an ischemic stroke now has disturbed sensory perception. what principle should guide the nurses care of this client? A) The client should be approached on the side where visual perception is intact B) attention to the affected side should be minimized in order to decrease anxiety C) the client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation D) the client should be approached on the opposite side of where the visual perception is intact to promote recovery

A

A client with Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this client. Nutritional management for a client with Huntington disease should be informed by what principle? A) The client is likely to have an increased appetite. B) The client is likely to require enzyme supplements. C) The client will likely require a clear liquid diet. D) The client will benefit from a low-protein diet.

A

A patient brought to the hospital after a skiing accident was unconscious for a level period of time at the scene, then woke up agitated and restless, then quickly lost consciousness again. What type of TBI is suspected to this situation? A) Epidural hematoma B) Acute subdural hematoma C) Chronic subdural hematoma D) Grade 1 concussion

A

An older adult has encouraged her husband to visit their primary provider, stating that she is concerned that he may have Parkinson disease. Which of the wife's descriptions of her husband's health and function is most suggestive of Parkinson disease? A) "Lately he seems to move far more slowly than he ever has in the past and there is a shuffle in his gait." B) "He often complains that his joints are terribly stiff when he wakes up in the morning." C) "He's forgotten the names of some people that we've known for years." D) "He's losing weight even though he has a ravenous appetite."

A

Cushing's triad is a late sign of increased intracranial pressure characterized by: A) Bradycardia, increasing systolic BP, bradypnea B) Bradycardia, narrowing pulse pressure, tachypnea C) Tachycardia, widening pulse pressure, bradypnea D) tachycardia, decreased urine output, increasing diastolic BP

A

The clinic nurse caring for a client with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide. What change in status would most clearly suggest a therapeutic benefit of this medication? A) Increased muscle strength B) Decreased pain C) Improved GI function D) Improved cognition

A

The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the client's safety, what nursing action should be performed? A) Ensure that suction apparatus is set up at the bedside B) Pad the patient's bed rails. C) Maintain bed rest whenever possible. D) Provide several small meals each day.

A

The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? A) Falls B) Audio hallucinations C) Respiratory depression D) Labile BP

A

What should the nurse do first when a client with a head injury begins to have clear drainage from his nose? A) Place a gauze under nose and test drainage for glucose B) Instruct the client to blow his nose C) Pack the nose with sterile gauze D) Gently suction the nose and mouth

A

Which statement by a client with seizure disorder and history of atrial fibrillation Taking carbamazepine (Tegretol) indicates the client requires further teaching? A) "I drink grapefruit juice every morning with breakfast" B) "I will have INR monitored frequently" C) "I will use other form of birth control in place of oral contraceptive" D) "I will notify PCP if I develop a rash"

A

SATA the nurse is planning discharge education for a client with trigeminal neuralgia. the nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client which might exacerbate pain? A) Face washing B) Chewing C) teeth brushing D) drinking large amounts of fluids E) earring puréed food

A B C

SATA a client with a history of epilepsy has consecutive seizures lasting more than five minutes and is in status epilepticus. Which interventions should be included in the client's immediate treatment? A) Administer lorazepam (Ativan) IV B) Administer oxygen and prepare for possible endotracheal intubation C) Prepare for immediate defibrillation D) Continue to protect the patient from injury E) Assess neurological function using GCS

A B D

SATA a nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the nurse should the nurse report to the provider? A) "I think I might be pregnant" B) "I take warfarin" C) "I take antihypertensive medication" D) "I am allergic to shrimp" E) "I ate breakfast this morning"

A B D E

SATA A client with a closed head injury has a sustained ICP 16-20mm Hg. which of the following actions should the nurse implement? A) Elevate the head of bed 30 to 45 degrees B) Suction client Q2 hr C) keep head positioned midline D) maintain CO2 15mmHg to prevent vasodilation E) administer a hypotonic IV solution to keep the patient hydrated

A C D

SATA A client with a spinal cord injury at the C6 vertebra level is at risk for autonomic dysreflexia. For which associated symptoms should the nurse monitor? A) Sweating B) Hypotension C) Headache D) Nasal congestion E) Tachycardia

A C D

SATA The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP? A) Change in level of consciousness B) Narrowing pulse pressure C) Pupils dilated and unequal D) Decorticate posturing to painful stimulus E) Tachycardia

A C D

The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead". Which data support brain death? A) When the clients head is turned to the right, the eyes turn to the right. B) The electroencephalogram (EEG) has identifiable waveforms C) There is no eye activity when to cold caloric test is performed D) The client assumes decorticate posturing when painful stimuli are applied

C

A nurse is preparing to administer phenytoin (Dilantin) to a 99lb client. The prescription reads: phenytoin 5mg/kg/day in 3 divided doses. How many milligrams should be administered in each dose? A) 45 mg B) 55 mg C) 65 mg D) 75 mg

D

A client with Parkinson disease is experiencing episodes of Constipation that are becoming increasingly frequent and severe. The client states that he has been achieving relief the past few weeks by using over the counter laxatives. How should the nurse respond? A) "It's important to drink plenty of fluids while you're taking laxatives" B) "Make sure that you supplement your laxatives with a nutritious diet" C) "let's explore other options, because laxatives can have side effects and create dependency." D) "You should ideally be using herbal remedies rather than medications to promote bowel function."

C

A client with Parkinson disease is undergoing a swallowing assessment due to a change in their swallowing ability. The client's nutritional needs should be met by what method? A) Total parenteral nutrition (TPN) B) Provision of a low residue diet C) Semisolid food with thick liquids D) Minced foods and a fluid restriction

C

A client with amyotrophic lateral sclerosis (ALS) and bulbar onset is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnosis is most likely for a client with this condition? A) Chronic confusion B) Impaired urinary elimination C) Impaired verbal communication D) Bowel incontinence

C

A client is brought to the Ed by ambulance with a gunshot wound to the abdomen.The nurse knows that the most common hollow organ injured in this type of injury is: A) Liver B) Small bowel C) Stomach D) Pancreas

B

A homeless patient is brought in by ambulance during a snowstorm. The client is suspected to be alcohol intoxicated. The client's core temperature is found to be 33.2 c (91.8F). What is the triage nurse's priority of care after assessing ABC's? A) Assessing for frostbite B) Addressing the client's hypothermia C) Addressing the client's intoxication D) Obtaining blood samples to send to the lab

B

A male client presents to the clinic reporting a headache. The nurse notes that the client is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well recognized sign of this infection? A) Negative Brudzinski sign B) Positive Kernig Sign C) Hyperpatellar reflux D) sluggish pupil reaction

B

A nurse in the ICU is providing care for a patient who has been admitted with a head trauma. The nurse is performing frequent neurologic assessments. Which of the following findings should be reported to the HCP immediately? A) MAP changes from 55 mmHg to 65 mmHg B) Glasgow coma scale changes from 13 to 5 C) ICP changes from 8 mmHg to 10 mmHg D) CPP changes from 90 mmHg to 70 mmHg

B

A nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? A) Taking a hot bath at least once daily B) Resting in an air-conditioned room whenever possible C) Increasing the dose of muscle relaxants D) avoiding naps during the day

B

A nurse is obtaining a health history from a client who has cluster headaches. Which of the following is expected? A) Pain is bilateral across the posterior occipital area B) headache described as sharp, stabbing pain behind the eye C) client describes headache pain as dull and throbbing D) headache is relieved with increased physical activity

B

A nurse is teaching a client with left leg weakness to walk with a cane. Which of the following points about safe cane use should be included in the teaching? A) Lean on the cane to get in and out of a chair B) Hold the cane on the unaffected side C) Walk by moving the affected leg then the cane D) Hold the cane on left side & move unaffected leg first

B

A nurse is triaging patients after a chemical leak at a nearby fertilizer factory.The guiding principle when triaging during a mass casualty incident is: A) Assigning high priority to the most critical injuries B) Doing the greatest good for the greatest number of people C) Allocating resources to the youngest and most critical D) Allocating resources to the first come, first serve basis

B

The clinic nurse caring for a client with Parkinson disease notes that the client has been taking levodopa and carbidopa (Sinemet) for 7 years. which effect should the nurse assess with this client? A) Pruritus B) Reduced effectiveness C) Lactose intolerance D) Diarrhea

B

The nurse is caring for a client who had a hemorrhage stroke. What assessment finding constitutes an early sign of deterioration? A) Generalized pain B) Alteration in level of consciousness (LOC) C) Tonic-clonic seizures D) Shortness of breath

B

The patient with a diagnosis of myasthenia gravis (MG) is admitted to the ER with increased weakness. It is determined the patient is experiencing a cholinergic crisis. the nurse understands that this is due to: A) A recent virus or flu that caused an exacerbation and worsening of the disease B) An excessive intake of the medications prescribed to treat the patients MG C) Extrapyramidal symptoms from the lack of dopamine D) Tardive dyskinesia from the meds

B

The triage nurse is caring for patients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory, skin and eye protection. What level of protection is this considered? A) Level A B) Level B C) Level C D) Level D

B

A nurse assesses a confused client who had a severe head injury. Baseline vital signs were BP 114/76, pulse 78, resp 18. Which assessment 2 hours later should cause most concern to the nurse? A) Pulse 94, BP 112 / 78 B) temp 97.6, pulse 90 C) BP 152 / 70, pulse 50 D) Pupils constrict equally, Resp 14

C

SATA when caring for a patient with Guillain-Barre syndrome (GBS) the nurse is aware of which potential complications? A) Thrombophlebitis B) Respiratory compromise C) Cardiac arrhythmias D) Hemorrhage E) Pressure ulcers

B C E

A patient is admitted a patient to the neurological intensive care unit with a brain stem herniation. The nurse has determined that the patients mean arterial pressure (MAP) is 60 with an intra cranial pressure (ICP) reading of 15 mm Hg. the nurse would be correct in determining the cerebral perfusion pressure (CPP) as which of the following values? A) Normal B) High C) Low D) Compensating

C

A patient who has been on the long-term phenytoin (Dilantin) Therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patient's plan of care? A) Monitoring of pulse oximetry B) administration of a low protein diet C) administration of thorough oral hygiene D) fluid restriction as ordered

C

The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? A) Epistaxis B) babinski reflex C) bruising over the mastoid D) unilateral facial numbness

C

A client has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? A) Place the client in the flat position for 30 minutes per day B) Assist the client in acutely flexing the thigh to promote movement C) Position a pillow between the arm & thorax to prevent shoulder abduction D) Place client's hand in pronation

C

A client is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? A) Serial assessments of hemoglobin levels B) Blood glucose monitoring C) Close monitoring of fluid and electrolyte balance D) Assessment of pain along dermatomes

C

A client is brought to the Ed by ambulance. The paramedics state that the patient was using cocaine at a party. On arrival, the patient appears in distress and is found to have a core temperature of 104 degrees Fahrenheit. What would be the priority nursing action for this patient? A) Initiate intravenous hydration as per MD order B) Administer antipyretics C) Ensure airway and ventilation D) Prevent seizure activity

C

A client suffered a head injury and is emerging from a coma. The client is confused and restless and keeps trying to pull out his NGT tube. The nurse should first. A) Apply wrist restraint to the client's arm B) contact the provider for a sedation order C) place mitts on the client hands D) remove the NG tube

C

A client who fell during a rock-climbing trip is alert and conscious but unable to move her arms or legs on command. When planning to move a person with a possible spinal cord injury, which of the following would be the priority concern? A) Wrapping and supporting the extremities, which can be easily injured B) Moving the person gently to help reduce pain C) Immobilizing the head and neck to prevent further injury D) Cushioning the back with pillows to ensure comfort

C

The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which pre-procedure teaching should the nurse implement? A) Tell the client to take any routine antiseizure medication prior to the EEG B) Instruct the client not to eat anything for (8) hours prior to the procedure C) Instruct the client to avoid caffeine and stimulant medications prior to the procedure D) Tell the client not to wash their hair the morning of the procedure

C

The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate? A) A subarachnoid hemorrhage B) An overwhelming infection C) A normal finding the fluid will be sent to determine other factors D) Local trauma from the insertion of the needle

C

The nurse is caring for the following clients. Which client would the nurse assess first after reviewing the shift report? A) The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every (2) hours B) The 16-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. C) The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow coma scale score of 6 D) The 62-year-old client diagnosed with bro vascular accident (CVA) who has expressive aphasia.

C

You are the triage nurse during an MCI event in New York City. A client arrives with a disaster tag showing red, this indicates: A) Urgent- injuries are significant and require medical care but can wait hours without B) Non-urgent- injuries are minor, and treatment can be delayed hours to days C) Emergent injuries are life threatening but survivable with minimal intervention D) Expectant- injuries are extensive, and chances of survival are unlikely even with definitive care

C

An elderly patient is being discharged home. The patient lives alone and has impairment of cranial nerve I olfactory. The nurse tells the patient's family that it is essential that the patient have what installed in the home? A) Grab bars B) Nonslip mats C) baseboard heaters D) a smoke detector

D

The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan? A) Encourage client to void every hour B) order a low-residue diet C) provide total assistance with all ADL'S D) instruct the client on daily muscle stretching

D

What should the nurse suspect when hourly assessment of urine output post craniotomy patient exhibits a urine output from a catheter of 1500 mL for 2 consecutive hours? A) Cushing's syndrome B) syndrome of inappropriate antidiuretic hormone C) adrenal crisis D) Diabetes Insipidus

D

While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the client's cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action? A) Page the healthcare provider and report this sign of infection B) Reinforce the dressing and reassess in 1 to 2 hours C) Reposition the client to prevent further hemorrhage D) Inform the surgeon of the possibility of a CSF dural leak

D

A client with a cerebral aneurysm exhibit signs and symptoms of an increase in intracranial pressure. What nursing intervention would be most appropriate for this client? A) Passive range of motion exercises to prevent contractures B) Supine positioning C) Early initiation of physical therapy D) Absolute bed rest in a quiet, non-stimulating environment

D

A nearby factory explosion has left a 40-year-old man with full thickness burns over 75% of his body. he is unresponsive on arrival period how would this person be triaged? A) Red B) Yellow C) Green D) Black

D