Exam 5

A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (tPA)? - Ask what medications the client is taking. - Complete a history and health assessment. - Identify the time of onset of the stroke. - Determine if the client is scheduled for any surgical procedures.

Identify the time of onset of the stroke

A client presents with severe headache, blurred vision, anxiety and confusion. The client's blood pressure is 224/137 mm Hg. The family reports that the client has hypertension, but has not been taking the prescribed blood pressure medications. The nurse anticipates giving which medication? - Norepinephrine - Amiodarone - Methotrexate - Labetalol

Labetalol

When assessing the client with Parkinson's disease, the nurse should observe the client for: - dry mouth. - aphasia. - an exaggerated sense of euphoria. - a stiff, masklike facial expression.

a stiff, masklike facial expression

Friends come to visit a client admitted with new-onset ischemic stroke. The stroke has caused aphasia and right-sided weakness. The client has an advance directive and an identified healthcare power of attorney. The friends ask the nurse about the client's condition. How should the nurse respond? - "I'm not at liberty to discuss their condition with you. You'll have to speak to the client's power of attorney if you'd like information." - "I can't tell you anything about the client's condition." - "You'll have to ask the client how they're feeling." - "The client is unable to communicate as a result of a stroke, so I'll tell you what I think they'd want you to know."

"I'm not at liberty to discuss their condition with you. You'll have to speak to the client's power of attorney if you'd like information."

The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. What information should the nurse include in the teaching plan? - "You'll need to accept the necessity for a quiet and inactive lifestyle." - "Keep active, use stress reduction strategies, and avoid fatigue." - "Follow good health habits to change the course of the disease." - "Practice using the mechanical aids that you'll need when future disabilities arise."

"Keep active, use stress reduction strategies, and avoid fatigue."

A nurse has a client with multiple sclerosis who, after attending a meeting with the Multiple Sclerosis Society, states complementary therapies would work better. What is the best response by the nurse? - "If you let us continue with your medical care, you'll get better more quickly." - "Most complementary therapies don't have evidence-based research supporting the practices. Do you want to take chances with your health?" - "Your medical treatments must not be working, because your condition appears to have deteriorated since the last time I saw you." - "You have a right to search out options and make decisions to help manage your symptoms. Share with me what you've learned."

"You have a right to search out options and make decisions to help manage your symptoms. Share with me what you've learned."

In which circumstance may the nurse legally and ethically disclose confidential information about a client? - A single client's human immunodeficiency virus (HIV) status to the family members - A diagnosis of pancreatic cancer to a client's significant other - A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency - The fact that a woman is 32 weeks pregnant with twins to the partner from whom she is legally separated

A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency

The nurse is assisting a client from the bed to a chair when the client begins having a generalized seizure. Which action should the nurse take first? - Administer 5 mg diazepam IV. - Obtain a full set of vital signs. - Record the type of seizure and how long it lasted. - Assist the client to a side-lying position on the floor.

Assist the client to a side-lying position on the floor

A client is discharged to home following hospitalization for percutaneous endoscopic gastrostomy tube placement to assist with nutrition. The client's primary diagnosis is amyotrophic lateral sclerosis (ALS). The client can transfer from the bed to a chair but can't walk. The client and their family are concerned about the client's ability to maintain mobility at the highest possible level following a surgical procedure. The nursing diagnosis most appropriate for this client is - Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate. - Caregiver role strain related to care recipient's unrealistic expectations of caregiver. - Impaired memory related to reduced quality and quantity of information processed. - Hopelessness related to impaired ability to cope.

Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate

A client with a new diagnosis of myasthenia gravis asks, "What is happening to me?" What would be the most appropriate response by the nurse? - It is a debilitating disease in which patches of nerves lose their myelin sheath, which interferes with nerve transmission to the muscles. - It is a chronic disease in which there is a disturbance in nerve transmission to the muscle, resulting in fatigue and muscle weakness. - It is an inherited disorder in which there is progressive destruction of the basal ganglia in the cerebral cortex. - It is a progressive, degenerative process involving spinal and lower motor neurons with spastic changes in cranial and spinal nerves.

It is a chronic disease in which there is a disturbance in nerve transmission to the muscle, resulting in fatigue and muscle weakness

A home health nurse is visiting a client with Alzheimer's disease who lives with two adult children. The nurse notes bruising on the client's upper arms. The client is more withdrawn than normal and is unable to communicate effectively because of the disease. What is the priority action by the nurse? - Ask the client's children why the client has bruises. - Monitor the client's condition during subsequent visits. - Report suspicion of elder abuse to the local agency for older adults. - Order diagnostic tests including blood work and X-rays.

Report suspicion of elder abuse to the local agency for older adults

The nurse observes that when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? - The tremors are probably psychological and can be controlled at will. - The tremors sometimes disappear with purposeful and voluntary movements. - The tremors disappear when the client's attention is diverted by some activity. - There is no explanation for the observation; it is a chance occurrence.

The tremors sometimes disappear with purposeful and voluntary movements

The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which intervention should the nurse consider? - Have the client hyperextend the neck when swallowing. - Tell the client to place the chin firmly against the chest when eating. - Thicken all liquids before offering to the client. - Place the client on a clear liquid diet.

Thicken all liquids before offering to the client

A client with quadriplegia is experiencing severe muscle spasms. To relieve them, a physician orders baclofen, 5 mg P.O. three times daily. What is the principal indication for baclofen? - acute, painful musculoskeletal conditions - skeletal muscle hyperactivity secondary to cerebral palsy - spasticity related to stroke - muscle spasms with paraplegia or quadriplegia from spinal cord lesions

muscle spasms with paraplegia or quadriplegia from spinal cord lesions

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction? - "Don't eat anything for 12 hours before the test." - "Don't shampoo your hair for 24 hours before the test." - "Avoid stimulants and alcohol for 24 to 48 hours before the test." - "Avoid thinking about personal matters for 12 hours before the test."

"Avoid stimulants and alcohol for 24 to 48 hours before the test"

An adolescent girl with a seizure disorder controlled with phenytoin and carbamazepine asks the nurse about getting married and having children. Which response by the nurse would be most appropriate? - "You probably should not consider having children until your seizures are cured." - "Your children will not necessarily have an increased risk of seizure disorder." - "When you decide to have children, talk to the health care provider about changing your medication." - "Women who have seizure disorders commonly have a difficult time conceiving."

"When you decide to have children, talk to the health care provider about changing your medication."

A client admitted with acute pyelonephritis now reports having a severe migraine, but declines PRN analgesics. What should the nurse discuss with this client? Select all that apply: - The client with pyelonephritis cannot use analgesics. - Ask the client which migraine treatments are helpful when at home. - Alternative therapies such as relaxation or music can help. - Short-term use of opioids has a high addiction risk. - Using opioids will prolong the inpatient hospital stay.

- Ask the client which migraine treatments are helpful when at home. - Alternative therapies such as relaxation or music can help.

A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac catheterization that involved a femoral puncture. The client is reminded to keep their leg straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is responsible for three other clients who underwent cardiac catheterization. What's the best step the nurse can take? - Continually remind the client not to move their leg and to leave the immobilizer alone. - Sedate the client. - Apply wrist restraints. - Ask the staffing coordinator to assign a nursing assistant to sit with the client.

Ask the staffing coordinator to assign a nursing assistant to sit with the client

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? - Limit fluid intake to 1,000 mL/day. - Insert an indwelling urinary catheter. - Establish a regular voiding schedule. - Administer prophylactic antibiotics, as prescribed.

Establish a regular voiding schedule

Which action should be the priority when caring for a school-age child admitted to the pediatric unit with the diagnosis of Guillain-Barré syndrome? - Assess the child's ability to follow simple commands. - Evaluate the child's bilateral muscle strength. - Make a game of the range-of-motion exercises. - Provide the child with a diversional activity.

Evaluate the child's bilateral muscle strength

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do? - Have the UAP keep a steady pull on the client to promote forward ambulation. - Explain how to overcome a freezing gait by telling the client to march in place. - Assist the UAP with getting the client back in bed. - Give the client a muscle relaxant.

Explain how to overcome a freezing gait by telling the client to march in place

A client is receiving a transfusion of packed red blood cells. What should the nurse do to safely administer the blood? - Keep the blood refrigerated on the nursing unit until ready to administer. - Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction. - Do not infuse blood that has been hanging for more than 6 hours. - Administer the blood quickly to prevent wasting it if the client develops a fever.

Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction

When the nurse is obtaining a health history from an older adult, which information in the history is a risk factor associated with deep vein thrombosis (DVT)? - The client walks 30 minutes every day. - The client lives alone. - The client recently had abdominal surgery. - The client wears support stockings.

The client recently had abdominal surgery

Which client should the nurse assess first? - a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain - a client with peripheral vascular disease with a blood pressure of 190/102 mm Hg who is due to receive a scheduled beta blocker - a client with a history of cerebral vascular attack, right sided weakness, blood pressure of 180/96 mm Hg who has a headache - a client with type 1 diabetes with a fasting blood glucose of 102 mg/dL, blood pressure of 172/90 mm Hg and whose urine shows microalbuminuria

a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain

A client has been admitted to the emergency department. The client's family tells the nurse that the client has suddenly become lethargic and is "not making sense." The client has not had anything to eat or drink for the last 8 hours. The nurse further assesses the client using the Confusion Assessment Method (CAM). The client's responses to questions are rambling, and the client is not able to focus clearly to answer the nurse's questions. Based on these findings, the nurse should report that the client has which problem? - dementia - depression - delirium - dehydration

delirium

The children of an elderly client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their parent's bedside tomorrow to make recommendations for client's care. Which considerations should the nurse prioritize in light of the practitioner's planned visit? - ensuring any complementary therapies are safe when combined with his prescribed therapy - identifying whether the family would prefer to pursue alternative or conventional treatment for their parent - ensuring that the care team does not impose their beliefs on the family or the complementary practitioner - taking measures to prevent cultural conflict when the practitioner comers to the hospital

ensuring any complementary therapies are safe when combined with his prescribed therapy

A charge nurse is completing client assignments on a neurologic unit. One full-time nurse from the unit, two floating nurses, and one agency nurse are present for the shift. The charge nurse should assign the unit's full-time nurse to care for the client who - has chronic back pain 1 day after having a laminectomy. - has a seizure disorder but has been seizure-free for 24 hours. - had a craniotomy 24 hours earlier for a brain hemorrhage. - has had a stroke and will transfer to the rehabilitation unit during the shift.

had a craniotomy 24 hours earlier for a brain hemorrhage

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? - heparin sodium - dexamethasone - methyldopa - phenytoin

heparin sodium

A client with a diagnosis of alcohol intoxication and suspected alcohol dependence is admitted to the psychiatric unit. Other assessment findings include an enlarged liver; jaundice; lethargy; and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what should the first priority be? - instituting seizure precautions, obtaining vital signs frequently, and recording fluid intake and output - checking the client's medical records for health history information - attempting to contact the family to obtain more information about the client - restricting fluids and leaving the client alone to "sleep off" the episode

instituting seizure precautions, obtaining vital signs frequently, and recording fluid intake and output

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should - place a heating pad around the affected calf. - elevate the affected leg as high as possible. - keep the affected leg level or slightly dependent. - shave the affected leg in anticipation of surgery.

keep the affected leg level or slightly dependent

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should - place the client on their back, remove dangerous objects, and insert a bite block. - place the client on their side, remove dangerous objects, and insert a bite block. - place the client on their back, remove dangerous objects, and hold down their arms. - place the client on their side, remove dangerous objects, and protect their head.

place the client on their side, remove dangerous objects, and protect their head

A client at risk for deep vein thrombosis (DVT) is prescribed antiembolism stockings. What should the nurse instruct the client about the purpose of these stockings? - supports the muscles to enhance ambulation - provides warmth to the lower extremities - thins the blood in the lower extremities - promotes venous blood return from the extremities

promotes venous blood return from the extremities

The nurse observes a visitor having a tonic-clonic seizure on the floor in the hallway of the acute care floor. What is the nurse's appropriate intervention when caring for the visitor? - placing an object between the teeth to prevent airway obstruction - restraining the visitor to prevent harm - protecting the visitor's head with a pad to prevent injury - laying the visitor on the back

protecting the visitor's head with a pad to prevent injury

The healthcare provider prescribes aspirin 325 mg by mouth each day for a client diagnosed with a transient ischemic attack (TIA). During education, how should the nurse identify the purpose of this medication? - controls headache pain - enhances the immune response - prevents intracranial bleeding - reduces the chance of blood clot formation

reduces the chance of blood clot formation

A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: - showing the location of the obstruction and the collateral circulation. - scanning the affected extremity and identifying the areas of volume changes. - using ultrasound to estimate the velocity changes in the blood vessels. - determining how long the client can walk.

showing the location of the obstruction and the collateral circulation

A nurse is preparing a teaching plan for a client with thromboangiitis obliterans (Buerger's disease). Which goal is the highest priority for this client? - stop smoking - avoid trauma to extremities - begin a walking exercise program - report wounds promptly to healthcare provider

stop smoking

A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside? - sphygmomanometer - padded tongue blade - nasal cannula and oxygen - suction machine with catheters

suction machine with catheters

Which is not a typical clinical manifestation of multiple sclerosis (MS)? - double vision - sudden bursts of energy - weakness in the extremities - muscle tremors

sudden bursts of energy

Which goal is the most realistic for a client diagnosed with Parkinson's disease? - to cure the disease - to stop progression of the disease - to begin preparations for terminal care - to maintain optimal body function

to maintain optimal body function