Med Surg Final Questions

D. To maintain optimal body function

Which goal is the most realistic and appropriate for client diagnosed with Parkinson's disease? A. To cure the disease B. To stop progression of the disease C. To begin preparations for terminal care D. To maintain optimal body function

C. The client will develop cognition

Which of the following is an inappropriate outcome to establish with a client who has MS? A. The client will develop joint mobility B. The client will develop muscle strength C. The client will develop cognition D. The client will develop mood elevation

B. Muscle rigidity

***A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which of the following indicates effective therapy? A. Mood B. Muscle rigidity C. Appetite D. Alertness

C. Monitor the client's serum blood glucose levels frequently

***The client diagnosed with an acute exacerbation of multiple sclerosis is placed in high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented? A. Discuss discontinuing the proton pump inhibitor with the HCP B. Hold the medication until after all cultures have been obtained C. Monitor the client's serum blood glucose levels frequently D. Provide supplemental dietary sodium with the client's meals

B. Sudden bursts of energy

***Which of following is not a typical clinical manifestation of multiple sclerosis (MS)? A. Double vision B. Sudden bursts of energy C. Weakness in the extremities D. Muscle tremors

C. Attempt to divert the client's attention

A client is experiencing mood swings after a CVA and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? A. Sit quietly with the client until the episode is over B. Ignore the behavior C. Attempt to divert the client's attention D. Tell the client that this behavior is unacceptable

C. " Is there any history of drug and/or alcohol abuse?"

A 46-year-old man is found in his home unconscious by his wife. The client is transported to the emergency department via life squad but remains unconscious. As the client is being assessed by the physician, the nurse gathers details from the client's wife as to possible causes. What question is most appropriate to assist in determining whether the unconsciousness is related to a coma or stroke? A. " How has your husband been sleeping at night?" B. " Has your husband complained of weakness in his lower legs in the past?" C. " Is there any history of drug and/or alcohol abuse?" D. " Has your husband had any seizures recently or does he have a history of seizures?"

A. Prevent the use of rectal thermometers

A client has received thrombolytic therapy for a thrombolytic stroke. The nurse knows that hemorrhaging is a potential complication of the therapy. What intervention would the nurse choose to prevent the possibility of bleeding? A. Prevent the use of rectal thermometers B. Monitor the international normalization ratio (INR) every 6 hours C. Keep the pathway to the bathroom clear D. Limit the number of intramuscular injections

A. Impaired Tissue Perfusion: Cerebral

A client is admitted with a hemorrhagic brain attack as a result of uncontrolled hypertension. The client complains of left-sided weakness and left-sided facial drop. Which potential complication would be a priority nursing diagnosis? A. Impaired Tissue Perfusion: Cerebral B. Impaired Mobility C. Altered Nutrition D. Risk for Injury: Falls

C. Atrial fibrillation

A client is brought to the emergency department after experiencing right-sided weakness and slurred speech. Which of the following health conditions in the client's history puts the client at risk for an embolic stroke? A. Restless legs syndrome B. Hypertension C. Atrial fibrillation D. Diabetes

B. Maintain the client on complete bed rest

A client who has recently been diagnosed with an aneurysm and been placed on aneurysm precautions will have which of the following incorporated into his plan of care? A. Elevate the head of the bed to 45 degrees B. Maintain the client on complete bed rest C. Administer enemas when the client is constipated D. Avoid use of thigh-high elastic compression stockings

B. Praise the client for her desire to be independent and give her extra time and encouragement

A client with Parkinson's disease needs a long tome to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which statement is the nurse's best initial response in this situation? A. Tell the client firmly that she needs assistance and help her with her care B. Praise the client for her desire to be independent and give her extra time and encouragement C. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help D. Suggest to the client that if she insists on self-care, she should at least modify her routine

B. Place the client in a quiet room and subdued lighting

A client with Parkinson's disease was recently offered early retirement from his company. He presents today with an exacerbation of tremors, rigidity, and bradykinesia. He is diaphoretic and experiencing tachycardia. The nurse should: A. Check the client's serum blood glucose level B. Place the client in a quiet room and subdued lighting C. Encourage the client to take slow deep breaths D. Prepare to start intravenous fluids and electrolytes

A. Keeping the pathway to the bathroom clear

A client with a frontal lobe infarct brain attack is being admitted to the rehabilitation nursing unit. The admitting nurse is to develop a plan of care. Which intervention would be beneficial to protect the client from potential injury? A. Keeping the pathway to the bathroom clear B. Providing verbal instructions on activity restrictions C. Keeping the call light within reach at all times D. Requiring a consult from the occupational therapy department

B. Fiber, stool softener, and prn laxative

A nurse is reviewing orders for a client diagnosed with brain attack who is being admitted to a rehabilitation nursing unit. The physician has ordered vital signs and neurological assessment every 4 hours for 48 hours, saline lock, and physical therapy, occupational therapy, and speech therapy to evaluate and treat. What additional orders should the nurse expect? A. D5 1/2 NS with 20 mEq KCL@100 mL/hr B. Fiber, stool softener, and prn laxative C. Bed rest, with client out of bed only with therapy D. Intermittent catheterization every 4 hours health care provider

B. Using a picture board

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? A. Speaking loudly B. Using a picture board C. Writing directions so client can read them D. Speaking in short sentences

D. "You will need to hold your head very still during the examination."

It is the night before a client is to have a computed tomographic (CT) scan of the head without contrast. Which statement by the nurse would be most appropriated? A. "You must shampoo your hair tonight to remove all oil and dirt" B. "You may drink fluids until midnight; but after that drink nothing until the scan is completed." C. "You will have some hair shaved to attach the small electrode to your scalp." D. "You will need to hold your head very still during the examination."

C. Dissolved emboli

What is the expected outcome of thrombolytic drug therapy for CVA? A. Increased vascular permeability B. Vasoconstriction C. Dissolved emboli D. Prevention of hemorrhage

B. Encourage the client not to write message

When communication with a client who has aphasia. Which of the following nursing interventions is inappropriate? A. Present one thought at a time B. Encourage the client not to write message C. Speak with normal volume D. Make use of gestures

D. Readminister the residual to the client and continue with the feeding

The client is to receive 200 mL of tube feeding every 4 hours. When the nurse checks for the client's gastric residual before administering the next schedule feeding and obtains 40 mL of gastric residual , what is the appropriate intervention? A. Withhold the tube feeding and notify the physician B. Dispose of the residual and continue with the feeding C. Delay feeding the client for 1 hour and then recheck the residual D. Readminister the residual to the client and continue with the feeding

D. Encouragement and patience

The client who has had a CVA with residual physical handicaps becomes discouraged by his physical appearance. What attitudes is best for the nurse to display to help the client overcome his negative self- concept? A. Helpfulness and sympathy B. Concern and charity C. Directives and firmness D. Encouragement and patience

C. Maintaining a safe environment

The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which of the following topics that the nurse plans to discuss is the most important? A. Maintaining a balanced nutritional diet B. Enhancing the immune system C. Maintaining a safe environment D. Engaging in diversional activity

D. Elevate head of bed 30 degrees, and then notify the health care provider

The nurse is assisting a client with a diagnosis of brain attack. The nurse finds the client lethargic and unable to clearly state an appropriate response to the nurse's questions. What should the nurse do? A. Place the client in Trendelenburg position with the head in a neutral position B. Document findings. Check again in 15 minutes when the client is awake C. Request a speech therapy consult from the health care provider D. Elevate head of bed 30 degrees, and then notify the health care provider

C. Positioning the hands in a slightly pronated position

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm. What position would be inappropriate? A. Placing a pillow in the axilla so that the arm is away from the body B. Placing a pillow under the slightly flexed arm so that the hand is higher than the elbow C. Positioning the hands in a slightly pronated position D. Positioning a roll in the hand so that the fingers are barely flexed

B. Restricting the diet to liquids until swallowing improves

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is inappropriate? A. Maintaining an upright position B. Restricting the diet to liquids until swallowing improves C. Introducing foods on the unaffected side of the mouth D. Keeping distractions to a minimum

D. Turn the head from side to side when walking

The nursing is teaching the client about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? A. Wear a patch over one eye B. Place personal items on the sighted side C. Lie in bed with the unaffected side toward the door D. Turn the head from side to side when walking

B. Eating food in only half of the plate

Which food-related behaviors would the nurse observe in a client who has had a CVA that has left him with homonymous hemianopia? A. Increased preference for foods high in salt B. Eating food in only half of the plate C. Forgetting the names of foods D. Inability to swallow liquids

B. Avoid kitchen activities because of the risk of injury

Which of the following is inappropriate for the nurse to include in the discharge plan for a client with MS who has impaired peripheral sensation? A. Carefully test the temperature of bath water B. Avoid kitchen activities because of the risk of injury C. Avoid hot water bottles and heating pads D. Inspect the skin daily for injury or pressure points

B. Sliding the client to move her up in bed

Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis? A. Rolling the client into her side B. Sliding the client to move her up in bed C. Lifting the client when moving her up in bed D. Having the client help lift herself off the bed using a trapeze

C. Take antihypertensive medication as ordered

Which should be included in the discharge teaching information for a client hospitalized for a cerebral aneurysm? A. Intermittent seizure can be expected B. Take ibuprofen for complaints of a serious headache C. Take antihypertensive medication as ordered D. Drowsiness is normal for the first week after discharge