med surg final practice q

Which type of stroke is associated with endocardial disorders, has a rapid onset, and is likely to occur during activity. A embolic B thrombotic C intracerebral hemorrhage D subarachnoid hemorrhage

A embolic

Syndrome of inappropriate ADH (SIADH) is treated with which intervention? A fluid restriction B fluid resuscitation C salt restriction D potassium replacement

A fluid restriction

The nurse is assessing the integrity of a patient's ICP monitoring system. Which system issues require corrective interventions? Select al that apply. A kinked tubing B fluid in the tubing C loose connections D air bubbles in the system E catheter occluded by tissue

ACDE kinked tubing, loose connections, air bubbles in the system, catheter occluded by tissue

A thrombus in a cerebral artery doesn't always result in a loss of neurologic function because A body can dissolve clots B some brain tissue doesn't require a constant blood supply C there may be collateral circulation from the circle of Willis D neurologic deficits only result from occlusion of major arteries

C there may be collateral circulation from the circle of willis

A patient is admitted to the hospital with thyrotoxicosis. On physical assessment of the patient, what should the nurse expect to find? a. Hoarseness and laryngeal stridor b. Bulging eyeballs and dysrhythmias c. Elevated temperature and signs of heart failure d. Lethargy progressing suddenly to impairment of consciousness

b. high temo and HF

Which problems can cause secondary injury? Select all that apply. A hypoxia B cerebral swelling C inflammation of cerebral tissue D skull fracture E ischemia

ABCE hypoxia, cerebral swelling, inflammation of cerebral tissue, ischemia

Which events cause increased ICP? Select all that apply. A vasodilation B necrotic cerebral tissue C blood vessel compression D edema from initial brain insult E brainstem compression and herniation

ABD vasodilation, necrotic cerebral tissue, edema form initial brain insult

Treatment of diabetes insipidus (DI) includes which interventions? Select all that apply. A fluid resuscitation B fluid restriction C administration of vasopressin D administration of phenytoin

AC fluid resuscitation, administration of vasopressin

What are the compartments within the brain? Select all that apply. A Blood B Bone C Brain tissue D Cerebrospinal fluid E Lacrimal

ACD Blood, brain tissue, cerebrospinal fluid

A client is scheduled for a total laryngectomy. The client tells the nurse, "I am worried about my operation. I just can't help it." Which response by the nurse is best

"I hear your concerns about having the operation."

The nurse presents information about immune thrombocytopenia purpura (ITP) to nursing students. A student asks "Which cells are destroyed when a client has ITP

" Which is the best response by the nurse? Platelets

On the evening before a scheduled lung biopsy, a client says to the nurse. "Do you think I have cancer

" Which response by the nurse is most appropriate?"You sound worried about what they might find tomorrow."

The home care nurse instructs a client diagnosed with Addison's disease about precautions to take to avoid an Addisonian crisis. Which client statement indicates teaching is successful

"I should increase my salt intake during very hot weather"

The nurse instructs staff members about care of a client diagnosed with cancer of the cervix. The client has internal radiation in place. The nurse should intervene if a staff member makes which statement

"I should place all linens in a special, lead-lined hamper."

The nurse instructs a group of clients about dietary habits to reduce the risk of cancer. Which statement, if made by a client to the nurse, indicates further teaching is necessary

"Eating polyunsaturated fats will decrease my chances of developing cancer."

Following a client's treatment for Addison's disease, the nurse plans for the clien't discharge. The cleint asks the nurse how long the medication must be continued. The nurse's response should include which information

"For the rest of your life"

The nurse counsels a client about preparation for a subtotal thyroidectomy. The client asks the nurse why the health care provider has proscribed a strong iodine solution. Which response by the nurse is best

"This medication will prevent postoperative hemorrhage"

The nurse cares for a client diagnosed with cancer receiving chemotherapy. The client shares with the nurse how upsetting losing the hair is. Which statement by the nurse is best

"Your hair will grow back about one month after chemotherapy is complete."

A nurse is planning care for a client who has Hgb 7.5 g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? select all 1. Provide assistance with ambulation 2. Monitor O2 saturation 3. Weigh client weekly 4. Obtain stool specimen for occult blood 5. Schedule daily rest periods

1. Provide assistance with ambulation 2. Monitor O2 saturation 4. Obtain stool specimen for occult blood 5. Schedule daily rest periods

Multiple sclerosis clinical manifestations (SELECT ALL THAT APPLY)

1.urinary retention 2.Hyperreflexia of the extremities. 3.Ataxia 4. Decreased concentration

Calculate the CPP for the patient with an ICP of 34 mm Hg and a systemic blood pressure 108/64 mm Hg.

108+ 2(64) ------------ = 78.6 78.6-34=44.6 3

A nurse is completing an integumentary assessment of a client who has anemia. Which of the following findings should the nurse expect? 1. Absent turgor 2. Spoon-shaped nails 3. Shiny, hairless legs 4. Yellow mucus membranes

2. Spoon-shaped nails Deformities of the nails are findings seen in a client with anemia.

A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in teaching? 1. Stool will be dark red 2. Take a glass of milk if GI distress occurs 3. Foods high in vitamin C will promote absorption 4. Take for 14 days

3. Foods high in vitamin C will promote absorption

Ondansetron HCl 6 mg PO q 6 hr is ordered for a client. The nurse knows which is the most appropriate time to administer this medication

30 minutes prior to start of chemotherapy.

Which client is at highest risk to develop iron deficiency anemia

A 60-year-old client with a bleeding gastric ulcer

The nurse performs health screening on a group of people. The nurse identifies which individual is at greatest risk of developing skin cancer

A 62-year-old male with light skin worked as a roofer for 40 years.

The localized matching of cerebral blood flow with cerebral metabolism occurs through which means? A autoregulation B anaerobic metabolism C luxury perfusion D cerebrospinal fluid

A Autoregulation

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of the following vital signs, if taken 1 hour after admission, will be of most concern to the nurse? A Blood pressure 156/60, pulse 55, respirations 12 B Blood pressure 130/72, pulse 90, respirations 32 C Blood pressure 148/78, pulse 112, respirations 28 D Blood pressure 110/70, pulse 120, respirations 30

A Blood pressure 156/60, pulse 55, respirations 12

Which structure is protective because it is the primary collateral pathway when major blood vessels are occluded? A Circle of Willis B Left internal carotid artery C right internal carotid artery D middle cerebral artery

A Circle of Willis

To assess the functioning of the trigeminal and facial nerves (CN V and VII), the nurse should: A apply a cotton wisp strand to the cornea. B have a patient read an magazine or book. C shine a bright light into the patient's pupil. D check for unilateral drooping of the eyelids

A apply a cotton wisp strand to the cornea

ICP can be increased by anything that does what? A increases intracranial volume B results in high compliance C results in low elastance D decreases carbon dioxide levels

A increases intracranial volume

While admitting patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question? A Insert nasogastric tube. B Turn patient every two hours. C keep the head of the bed elevated. D Apply cold packs for facial bruising.

A insert nasogastric tube

An unconscious patient has a nursing diagnosis of ineffective cerebral perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? A Keep the head of the bed elevated to 30 degrees. B Position the patient with hips and knees flexed. C Encourage coughing and deep breathing to improve oxygenation. D Cluster nursing interventions to provide uninterrupted rest periods.

A keep the head of the bed elevated to 30 degrees.

While developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to: A prevent falls B stabilize mood C enhance swallowing ability D improve short term memory

A prevent falls

Emergency department admits pt from a multicar accident. Which of the following pt should the nurse attend to FIRST

A pt with clear fluid draining from the right ear

Which mechanism of injury commonly results in the tearing of axons in the brain? A rotational B acceleration C deceleration D penetrating

A rotational

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patient's food into small pieces. c. Provide high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms

A, B, D a. use elevated toilet seat b. cut food into small pieces d. put arm chair at pts bedside (give protein at night and theres no exacerbations)

Which statements accurately describe thrombocytopenia (select all that apply)? a. Patients with platelet deficiencies can have internal or external hemorrhage. b. The most common acquired thrombocytopenia is thrombotic thrombocytopenic purpura (TTP). c. Immune thrombocytopenic purpura (ITP) is characterized by increased platelet destruction by the spleen. d. TTP is characterized by decreased platelets, decreased RBCs, and enhanced aggregation of platelets. e. A classic clinical manifestation of thrombocytopenia that the nurse would expect to find on physical examinationof the patient is ecchymosis.

A, C, D a. internal/external hemorrhage c. ITP is platelet destruction by spleen d. TTP is decreased platelets/rbc (petechiae is most common sign but bruise)

Which findings are consistent with Cushing's Triad? Select all that apply. A Increase in systolic blood pressure B Unequal pupils C Bradycardia D Increase in diastolic blood pressure E Irregular resirations

A,C,E Increase in systolic BP, bradycardia, irregular respirations

A patient is diagnosed with Bell's palsy. What information should the nurse teach the patient about Bell's palsy (select all that apply)? a. Bell's palsy affects the motor branches of the facial nerve. b. Antiseizure drugs are the drugs of choice for treatment of Bell's palsy. c. Nutrition and avoidance of hot foods or beverages are special needs of this patient. d. Herpes simplex virus 1 is strongly associated as a precipitating factor in the development of Bell's palsy. e. Moist heat, gentle massage, electrical stimulation of the nerve, and exercises are prescribed to treat Bell's palsy. f. An inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is evident.

A,D,E,F a. Bell's palsy affects the motor branches of the facial nerve. d. Herpes simplex virus 1 is strongly associated as a precipitating factor in the development of Bell's palsy. e. Moist heat, gentle massage, electrical stimulation of the nerve, and exercises are prescribed to treat Bell's palsy. f. An inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is evident.

The nurse is caring for a patient who is admitted after head injury. When would the nurse obtain most of the data related to this patient's mental status? A During the nursing health history B While observing patient behaviors C While asking specific problem-solving questions D While reviewing answers on a written mental examination

A. During the nursing health history

The spouse of a client diagnosed with pernicious anemia asks why vitamin b12 can't be given in pill form. Which response by the nurse is best

Your spouse's stomach doesn't secrete the necessary substance for b12 to be absorbed orally.

a patient with a hematologic disorder has a smooth, shiny, red tongue. which laboratory result would the nurse expect to see? a. neutrophils 45% b. hgb 9.6 c. wbc 13,500 d. rbc 6.4

b. hgb

The nurse is caring for a client diagnosed with Addison's disease. How would the nurse expect the client's skin to appear

Abnormally dark and pigmented (bronze)

The nurse understands which of the following is the most significant risk factor for developing cancer

Advancing age

Nurse instructs a client diagnosed with Bell's palsy. It is MOST important for the nurse to make which statement about nighttime care

Apply an eye shield over the affected eye

Nurse in the outpatient clinic cares for a client diagnosed with Bell's palsy. Which action should the nurse take FIRST

Assess the client's pain experience

ICP remains relatively stable, and under normal conditions it is usually less than what amount? A 5 mm Hg B 15 mm Hg C 30 mm Hg D 50 mm Hg

B 15 mm Hg

After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? A Have the patient blow the nose. B Check the nasal drainage for glucose. C Reassure the patient that rhinorrhea is normal after head injury. D Obtain a specimen of the fluid to send for culture and sensitivity

B Check the nasal drainage for glucose

A patient with a right hemisphere stroke has unilateral neglect related to sensory-perceptual deficits. During the patient's rehabilitation, what nursing intervention is important for the nurse to do? A Place all objects on the unaffected side. B Teach the patient to care for the affected side. C Avoid positioning the patient on the affected side. D Protect the affected side with pillows and supports.

B Teach patient to care for the affected side

What does the Glasgow Coma Scale assess? A Cranial nerves B Arousal C Abstract thinking D Awareness

B arousal

A brief loss of consciousness followed by a period of being alert and oriented and then a loss of consciousness again is a typical presentation for which condition? A subdural hematoma B epidural hematoma C intracranial hematoma D subarachnoid hemorrhage

B epidural hematoma

Which statement is accurate regarding decompressive craniectomy? A It is appropriate for all patients with secondary injury. B It is used to treat intractable ICP elevation in some patients. C It will reduce CPP. D It will increase ICP

B it is used to treat intractable ICP elevation in some patients.

Presence of dizziness, headache, and confusion for long periods of time after concussion is: A expected B known as post-concussion syndrome C caused by taking too much pain medication D the result of something other than the concussion

B known as post-concussion syndrome

Which intervention should the nurse perform to reduce the ICP in a patient with a brain injury? A Fatten the head of the bed. B Maintain the head and neck in neutral alignment C Suction the patient every hour. D Slightly hypoventilate the patient.

B maintain the head and neck in neutral alignment

What is the appropriate food for a patient with a stroke who has mild dysphagia? A milkshakes B scrambled eggs C pureed food D fruit juice

B scrambled eggs

When using intraventricular ICP monitoring, what should the nurse be aware of to prevent inaccurate readings? A. The P2 wave is higher than the P1 wave. B. CSF is leaking around the monitoring device. C. The transducer of the ventriculostomy monitor is at the level of the upper ear. D. The drain of the CSF drainage device was closed for 6 minutes before taking the reading.

B. csf is leaking

What are common complications in a patient with an ICP monitoring device? Select all that apply. A new-onset seizures B overdrainage of CSF C collapsed ventricles D bleeding E infection

BDE overdrainage of CSF, bleeding, infection

After 2 weeks of chemotherapy treatments, a client's WBC count is 2,000/mm. The nurse knows this finding is most likely due to which factor

Bone marrow depression.

The nurse knows which is the most life-threatening side effect of chemotherapy

Bone marrow suppression.

A patient with a brain injury has developed a fever. The nurse is aware that the fever has to be treated immediately because of which reason? A It decreases venous return from the brain. B It often causes seizure activity. C It increases the brain's metabolic needs. D It may be caused by infection.

C It increases the brain's metabolic needs

A patient is admitted with left hemiplegia. To determine size, location, and differentiate between ischemic versus hemorrhagic, which diagnostic test may be ordered? A lumbar puncture B angiography C MRI D CT scan with contrast

C MRI (CT if w/o contrast)

A patient with right-sided brain stroke has a nursing diagnosis has a disturbed visual-sensory perception because homonymous hemianopsia. Early in the care of a patient, what should the nurse do? A Patch the affected eye so that the patient has to turn the head to scan the environment B Place objects on the left side to encourage the patient to turn the head C Place objects on the right side within the patient's field of vision D Place objects in the center of the patient's field of vision

C Place objects on the right side within the patient's field of vision

Why are cerebral arteries so prone to rupture during hypertension? A There are so many of them. B They have autoregulation. C They are thin and delicate. D They are not protected by skeletal muscle.

C They are thin and delicate

What primarily determines the neurologic functions that are affected by a stroke? A amount of tissue affected B rapidity of onset C area perfused by the affected artery D collateral circulation

C area perfused by the affected artery

A few days after a stroke, a patient is going to start oral fluids and feedings. Before feeding the patient, the nurse will do which of the following? A order a pureed diet B give water to check the patient's ability to swallow C Check the gag reflex D raise the head of the bed to the Fowler's position

C check the gag reflex

An early sign of increased ICP for which the nurse should assess is? A Cushing's triad B projectile vomiting C decreasing level of consciousness (LOC) D dilated pupil with sluggish response to light

C decreasing LOC

During the acute phase of a stroke, the nurse anticipates which cardiovascular sign as the body tries to increase cerebral blood flow? A Vasodilation B S3 and S4 heart sounds C hypertension D diminished peripheral pulses

C hypertension

What is the highest risk for stroke? A African Americans B Smokers C Hypertension and Diabetes D Obesiy with high fat intake

C hypertension and diabetes

A patient is admitted to the hospital with a cerebral contusion. During the night, he develops a headache, vomits, and seems more lethargic. What are the appropriate actions for the nurse to take? A Give the patient pain medication to treat the headache and reassess in one hour. B Give the patient antinausea medication and reassess in one hour. C Perform a neurological and pupillary assessment immediately. D Assess the patient's lung fields.

C perform a neurological and pupillary assessment immediately

A lack of comprehension of both verbal and written language is described as? A dysarthria B fluent aphasia C receptive aphasia D expressive aphasia

C receptive aphasia

What nursing intervention helps to prevent increased cerebral metabolism? A Maintaining CPP less than 60 mm Hg B Vigorous suctioning of the patient C Spacing patient care activities D Keeping the patient flat at all times

C spacing patient care activities

The nurse cares for a client immediately after a thyroidectomy. It is most important for the nurse to contact the health care provider if which is observed

Change in quality of respirations

Pt diagnosed with a spinal cord injury: T3. Pt complains of pounding headache and nasal congestion. Nurse notes that the patient has profuse sweating from the forehead and piloerection. Which of the following actions should the nurse take first

Check the Foley catheter and tubing for kinks.

Nurse notes a newly admitted patient diagnosed with a head injury has a clear nasal drainage. Which of the following actions should the nurse take FIRST

Check the nasal drainage for glucose

The home care nurse monitors a client diagnosed with cancer of the lung. The client complains about awakening with a severe headache several mornings during the past week. The client also admits to becoming suddenly nauseated, has vomiting, and notices drooling. Which of the following actions by the nurse is the best

Contact the physician.

The nurse understands that which statement best describes the action of glucocorticoids

Convert protein and fat into glucose

The home health nurse visits the client diagnosed with pernicious anemia 18 months after having a total gastrectomy. The client asks, why do I have this anemia

Which reason does the nurse give the client? Loss of mucosal surface that's accretes intrinsic factor

According to the Monro-Kellie hypothesis, an increase in one intracranial compartment must be accompanied by which reciprocal action? A Increase in the blood-brain barrier B Decrease in the blood-brain barrier C Increase in another compartment D Decrease in another compartment

D Decrease in another compartment

Which situation would cause an increase in ICP? A Decreased cerebral blood flow B Decreased CSF production C Increased cerebral venous drainage D Increased intrathoracic pressure

D Increased intrathoracic pressure

What is the nursing intervention that is indicated for the patient with hemiplegia? A footboard for the prevention of footdrop B affected arm in a sling C positioning in bed with each joint lower than the joint proximal to it D having the patient perform passive range of motion (PROM) of the affected limb with the unaffected limb

D having the patient perform passive range of motion (PROM) of the affected limb with the unaffected limb

Which drug treatment helps to decrease ICP by moving fluid via osmosis? A dexamethasone B oxygen administration C pentobarbital (Nembutal) D mannitol (Osmitrol)

D mannitol (Osmitrol)

A patient with a head injury is to receive mannitol in a dose of 0.5 grams/kg every 4-6 hours. This drug reduces ICP through which action? A Replaces lost fluid volumes to achieve a euvolemic state B Inhibits inflammation via action of natriuretic peptide C Increases resorption of water by the renal tubules D pulls fluid out of brain cells and into blood

D pulls fluid out of brain cells and into the blood

A patient with a brainstem infarction is admitted to the nursing unit. The priority assessment for the patient is: A reflex reaction time B pupil reaction to light C level of consciousness D respiratory rate and rhythm

D respiratory rate and rhythm

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for: A sensation on the left side of the body. B voluntary movement on the right side. C reasoning and problem-solving abilities. D understanding of written and oral language

D understanding of written and oral language

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient? a. Multivitamin (Stresstabs) b. Acetaminophen (Tylenol) c. Ibuprofen (Motrin, Advil) d. Diphenhydramine (Benadryl)

D. benadryl

Prior to insertion of a cervical radioactive implant, enemas are prescribed for the client. The nurse understands enemas are prescribed for which reason

Decrease the chance of the implant becoming dislodged.

It is important for the nurse to monitor a client with Addison's disease for the development of which condition

Dysrhythmias

After experiencing a TIA, a patient is likely to be placed on A warfarin B heparin C furosemide D vitamin K E aspirin

E aspirin

While the nurse ambulated the client to the bathroom, the client begins to have a seizure. Which of the following actions should the nurse take FIRST

Ease the pt to the floor

The nurse cares for a client with stomatitis due to chemotherapy. Which action is most important for the nurse to include in the client's plan of care

Examine the client's mouth for blisters, sores, or drainage.

The client diagnosed with iron deficiency anemia receives ferrous gluconate daily. The client asks the nurse, why do I have to dilute this iron and drink more fluids

Which response by the nurse is best? Undiluted iron stains teeth and causes Constipation

The nurse counsels a client diagnosed with iron deficiency anemia period the nurse determines teaching is effective if the client selects which menu

Flank steak, green leafy vegetables, and prunes

The client asks the nurse how long injections of vitamin B12 will be needed. Which response by the nurse is best

For the rest of your life

The nurse assesses a client with a diagnosis of colorectal cancer. The nurse understands that eating which food(s) may contribute to the client developing colon cancer

Fried red meat.

The home nurse cares for a client diagnosed with acute myelogenous leukemia (AML). The client's temp is 101. Which of the following actions should the nurse take first

Notify the physician

Nurse cares for a pt suspected of having a seizure disorder. The pt tells the nurse, "I smelled oranges today and there wasn't one on my tray." Which of the following responses by the nurse is BEST

Have you experienced this sensation before?

The nurse completes the client's admission history and physical examination. Which question does the nurse ask to obtain information related to symptoms of pernicious anemia

Have you noticed how long you have had these blisters on your feet

The nurse is caring for a patient with a diagnosis of possible stroke. The client's daughter reports that the client has a history of HTN that is not managed well. The client is taking antihypertensive med and hormone replacement therapy. The client's only activity is managing the home, and the client appears overweight. The nurse identifies which is the MOST important risk factor for this client to develop a stroke

Hypertension

The nurse educates the client diagnosed with iron deficiency anemia. Which client statement indicates the client needs further teaching

I don't have to worry about diet because I take iron preparations

The nurse in the outpatient clinic assesses a client diagnosed with trigeminal neuralgia. The nurse should intervene if the client says what

I drink coffee with breakfast and after dinner.

The nurse cares for a client after a subtotal thyroidectomy. The nurse identifies that damage to the parathyroid gland is indicated by which symptom

Numbness in the fingers

Meningitis. Nurse notes when client flexes the head, the client also flexes the hip and knee. Which actions by the nurse is BEST

Immediately report this finding to the health care provider (hcp).

The nursing intervention that is most effective in promoting adequate nutrition for clients undergoing radiation and chemotherapy

Include clients when making meal and snack selection.

The nurse assesses a client receiving levothyroxine sodium. Which indicates a favorable outcome to the nurse

Increased urine output

A client is evaluated in the outpatient clinic for hypothyroidism. The nurse expects the client to exhibit which symptom

Increasing fatigue

The nurse notes these lab values for a client: WBC 7,500, RBC 5 million, HGB 13. HCT 42.2%, and platelets, 18,000. Based on these laboratory results, which intervention does the nurse add to the client's care plan

Institute bleeding precautions

Nurses care for a pt diagnosed with a closed head injury and increased intracranial pressure. Which of the following actions by the nurse is BEST

Instruct the pt to exhale when turning or moving in bed

The nurse understands which is the most common type of anemia

Iron deficiency anemia

A client with hyperthyroidism tells the nurse of becoming very irritable. The nurse understands which about this symptom

Irritability is commonly observed in clients with hyperthyroidism

The adult male client's admitting blood work results are hematocrit 47%, HGB 15.5, RBC 5.3 mil, WBC 7,500, and platelets 50,000. Based on these lab results, which nursing action is most appropriate

Observe for signs and symptoms of bleeding

MOST realistic and appropriate nursing goal in planning care for a pt with Parkinson's disease

Maintain optimal fxn within the patient's limitations.

What should be the priority nursing goal of a pt with symptoms of myasthenia gravis

Maintain respiratory function

The nurse is leading a smoking cessation class. Which instruction should the nurse give first

Make a list of all the reasons to quit smoking.

The nurse cares for the client diagnosed with pernicious anemia. Which treatment does the nurse expect the health care provider to prescribe

Parental administration of vitamin B12 once a month

The client diagnosed with iron deficiency Anemia says to the nurse, "I have always been a picky eater." The clients menstrual flow is normal and no sources of occult bleeding were identified in the clients diagnostic work up. The nurse understands that which is the most likely cause of anemia

Poor nutrition

Nursing diagnosis of "Altered nutrition: less than body requirements related to inability to feed self," for a client with right-sided hemiplegia. Which intervention is MOST appropriate to improve the client's nutrition

Provide a pureed diet

The nurse assesses the dietary education provided to the client diagnosed with pernicious anemia period the client selection of which food indicates the teaching is effective

Red meat

The nurse cares for a client diagnosed with immune thrombocytopenia purpura. Which nursing diagnosis is a priority when caring for this client

Risk for injury

Nurse instructs the family of a patient diagnosed with Parkinson's disease. What statements by the family reflects a need for further education

We will buy lots of soup for dad

In teaching a client with Addison's disease about dietary needs, the nurse should empasize the importance of consuming which nutrient

Sodium

The nurse teaches the client diagnosed with iron deficiency anemia about dietary management of the anemia. At the end of the session, The client's selection of which foods indicate the client understands the teaching

Spinach and eggs

The nurse presents information on immune thrombocytopenia purpura (ITP) to nursing students. Which medication does the nurse expect to administer to a client with ITP

Steroids

The nurse teaches a client diagnosed with Graves' disease about diet. The nurse determines further teaching is required when the client selects which food

Tea

The home care nurse monitors a client 7 days after a transsphenoidal hypophysectomy. The nurse intervenes if which observation is made

The client brushes teeth morning and night

The nurse cares for a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse is most concerned if which is observed

The client is eating ice chips

The nurse provides care for a client diagnosed with immune thrombocytopenia purpura. The nurse encourages the client to read the labels of all medications, including over-the-counter medications, for the inclusion of aspirin. Which is the primary reason the nurse makes this recommendation

The client may have an increased risk for bleeding

The nurse performs a home care visit for a client receiving chemotherapy for treatment of cancer. The client's WBC count is 3,500 mm. Which of the following observations, if made by the nurse, requires the intervention

The client pulls weeds in the garden every day

The nurse makes a home visit to a client receiving chemotherapy for the treatment of cancer. The nurse instructs the client about ways to avoid injury due to bone marrow suppression. The nurse should intervene if which of the following is observed

The client takes Alka-Seltzer for indigestion.

The nurse cares for a client with diagnosed diabetes insipidus. The health care provider prescribes vasopressin. The nurse determines that the medication is effective if which observation is made

The client's specific gravity is 1.015

The nurse cares for a client diagnosed with cancer of the lung receiving chemotherapy. The nurse notes the client's platelet count is 60,000/mm. Which action by the nurse is most appropriate

The nurse checks the bristles on the client's toothbrush.

The nurse cares for a client diagnosed with immunosuppression due to chemotherapy. The nurse determines care is appropriate if which action is observed

The nursing assistive person washes hands prior to changing the client's bed linens.

The nurse cares for a patient admitted to the emergency room following an automobile accident. The patient complains of dizziness, and the physician suspects a head injury. The nurse should intervene if what is observed

The patient is leaning forward with his head over the knees

The clinic in the outpatient clinic cares for a client with the diagnosis of Cushing's disease. The nurse should expect to obsereve which symptom

Thin legs and arms

Nurse identifies the following manifestation is MOST characteristic of myasthenia gravis

Tiredness with slight exertion

Client with Glascow coma scale of 7. Nurse identifies it is important to give eye care to this patient for which reason

To prevent corneal irritation

Pt with Parkinson's has tremors of both upper arms. Nurse observes that the tremors disappear as the pt unbuttons his shirt. Which of the following indicates the most accurate understanding of tremors

Tremors decrease in severity when the attention is diverted by activity.

Which cranial nerves affected in tic douloureux

Trigeminal.

During the nursing history, the admitting nurse attempts to identify the aura of a client diagnosed with grand mal seizures. Which of the following statements accurately describes an aura

Unusual sensations prior to the seizure

The home care nurse visits a client undergoing external radiation for treatment of lung cancer. It is most important for the nurse to include which of the following interventions in the client's plan of care

Use a patting motion to dry the irradiated area.

The nurse advises a patient with myasthenia gravis (MG) to a. perform physically demanding activities early in the day. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy .d. protect the extremities from injury due to poor sensory perception.

a. do hard stuff early

in a patient with an elevated serum cortisol, what would the nurse expect other laboratory findings to reveal a. hypokalemia b. hyponatremia c. hypoglycemia d. decreased serum triglycerides

a. hypokalemia

After a hypophysectomy for acromegaly, postoperative nursing care should focus on a) frequently monitoring of serum and urine osmolarity b) parenteral administration of a GH-receptor antagonist c) keeping the patient in a recumbant position at all times d) patient teaching regarding the need for lifelong hormone therapy

a. monitor osmolality (looking for DI)

During the care of the patient with SIADH, what should the nurse do? a. Monitor neurologic status at least every 2 hours b. Teach the patient receiving tratment with diuretics to restrict sodium intake c. Keep the head of the bed elevated to prevent antidiuretic hormone (ADH) released. d. Notify the health care provider if the patient's blood pressure decreases more than 20 mm Hg from baseline

a. neuro q2h

A patient has a low serum T3 level. The HCP orders measurement of the TSH level. If the TSH level is elevated, what does this indicate? a. The cause of the low T3 level is most likely primary hypothyroidism. b. The negative feedback system is failing to stimulate the anterior pituitary gland c. The patient has an underactive thyroid gland that is not receiving TSH stimulation. d. A tumor on the anterior pituitary gland that is causing increased production of TSH

a. primary hypo

What is the most important method for identifying the presence of infection in a neutropenic patient? a. Frequent temperature monitoring b. Routine blood and sputum cultures c. Assessing for redness and swelling d. Monitoring white blood cell (WBC) count

a. temp

A patient with acromegaly is treated with a transsphenoidal hypophysectomy. What should the nurse do postoperatively? a. Ensure that any clear nasal drainage is tested for glucose b. Maintain the patient flat in bed to prevent cerebrospinal fluid (CSF) leakage. c. Assist the patient with toothbrushing every 4 hours to keep the surgical area clean d. Encourage deep breathing, coughing, and turning to prevent respiratory complications

a. test clear drainage for glucose

Which abnormal assessment findings are related to thyroid dysfunction (select all that apply)? a. Tetanic muscle spasms with hypofunction b. Heat intolerance caused by hyperfunction c. Exophthalmos associated with excessive secretion d. Hyperpigmentation associated with hypofunction e. A goiter with either hyperfunction or hypofunction f. Increase in hand and foot size associated with excessive secretion

b,c,e b. heat intolerance w hyper c. exop w hyper e. goiter

The patient is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What manifestation should the nurse expect to find? a. Decreased body weight b. Decreased urinary output c. Increased plasma osmolality d. Increased serum sodium levels

b. decreased output

The health care provider prescribe levothyroxine (Synthroid) for a patient with hypothyroidism . After teaching regarding this drug, the nurse determines that further instruction is needed when the patient says a) "I can expect the medication dose may need to be adjusted" b) "I only need to take this drug until my symptoms are improved" c) "I can expect to return to normla function with the use of this drug" d) "I will report any chest pain or difficulty breathing tot he Dr. right away"

b. i only need to take until my s/s improve (need to take for life)

in teaching the patient with pernicious anemia about the disease, the nurse explains that it results from a lack of a. folic acid b. intrinsic facto c. extrinsic factor d. cobalamin intake

b. intrinsic factor

in providing care for a patient hospitalized with an acute exacerbation of polycythemia vera, the nurse gives priority to which action a. maintaining protective isolation b. promoting leg exercises and ambulation c. protecting the patient from injury or falls d. promoting hydration with a large oral fluid intake.

b. leg exercises/ambulaton

Which intervention will be included in the nursing care plan for a patientwith immune thrombocytopenic purpura (ITP)? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

b. no IM

A 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting .b. Suggest that the patient rock from side to side to initiate leg movement .c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

b. rock side to side

A patient has a platelet count of 50,000/ and is diagnosed with ITP. What does the nurse anticipate that initialtreatment will include? a. Splenectomy b. Corticosteroids c. Administration of plateletsd . Immunosuppressive therapy

b. steroids

When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about urinary tract problems. c. inspect the skin for rashes or discoloration. d. ask the patient about any increase in libido.

b. urinary tract probs

Important nursing interventions when caring for a patient with Cushing syndrome include a) restricting protein intake b) monitoring blood glucose levels c) observing for signs of hypotension d) administering medication in equal doses e) protecting patient from exposure to infection

b. watch blood sugar e. protect from infection

Which components are able to change to adapt to small increases in intracranial pressure (ICP) (select all that apply)? a. Blood b. Skull bone c. Brain tissue d. Scalp tissue e. Cerebrospinal fluid (CSF)

bloood brain tissue CSF

An important preoperative nursing intervention before an adrenalectomy for hyperaldosteronism is to a) monitor blood glucose levels b) restrict fluid and sodium intake c) administer potassium sparing diuretics d) advise the patient to make postural changes slowly

c. K sparing diuretic (aldactone)

which factors decrease cerebral BLOOD FLOW (select all) a. increased ICP b. PaO2 45mmhg c. PaCO2 30mmhg d. arterial blood ph of 7.3 e. decreased MAP

c. PaCO2 e. decreased MAP

A patient with a head injury develops SIADH. Manifestations the nurse would expect to find would include. a) hypernatremia and edema b) muscle spasticity and hypertension c) low urine output and hyponatremia d) weight gain and decreased glomerular filtration rate

c. low output/na

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

c. resp effort

The patient has been diagnosed with a cerebral concussion. What should the nurse expect to see in this patient? a. Deafness, loss of taste, and CSF otorrhea b. CSF otorrhea, vertigo, and Battle's sign with a dural tear c. Boggy temporal muscle because of extravasation of blood d. Headache, retrograde amnesia, and transient reduction in LOC

d

The female patient is admitted with a new diagnosis of Cushings syndrome with elevated serum and urine cortisol levels. Which assessment findings should the nurse expect to see in this patient? a. Hair loss and moon face b. Decreased weight and hirsutism c. Decreased muscle mass and thick skin d. Elevated blood pressure and blood glucose

d. high bp/glucose

After thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops a) muscle weakness and weight loss b) hyperthermia and sever tachycardia c) hypertension and difficulty swallowing d) laryngospasms and tingling in hands and feet

d. laryngospasm/tingly

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury. b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury. c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC.

d. pass out, come to, pass out again

A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep veinthrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet leveldrops to 110,000/μL. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time .c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal saline.

d. stop heparin and flush saline

What is a major method of preventing infection in the patient with neutropenia? a. Prophylactic antibiotics b. A diet that eliminates fresh fruits and vegetables c. High-efficiency particulate air (HEPA) filtration rooms d. Strict hand washing by all persons in contact with the patient

d. wash hands

The nurse performs diet teaching for a client with iron deficiency anemia. The nurse determines teaching is successful if the client selects which menu

liver and onions, spinach, and rice pudding with raisins

The nurse cares for the client diagnosed with idiopathic thrombocytopenic purpura (ITP). which admission lab result does the nurse report immediately

platelet count 19,000

The nurse cares for the client diagnosed with severe anemia and notes the client has pallor of the skin, conjunctivae, and mucous membranes. which statement best explains the reason for the pallor

shunting of blood to heart and brain