Med Surg Mid Term
A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? A. Risk for infection B. Decreased cardiac output C. Impaired physical mobility D. Imbalanced nutrition: Less than body requirements
B
A client with osteoarthritis expresses concerns that the disease will prevent the ability to complete daily chores. Which suggestion should the nurse offer? A. "Do all your chores in the morning, when pain and stiffness are least pronounced." B. "Do all your chores after performing morning exercises to loosen up." C. "Pace yourself and rest frequently, especially after activities." D. "Do all your chores in the evening, when pain and stiffness are least pronounced."
C
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as: A. Mild TBI. B. Moderate TBI. C. Severe TBI. D. Brain death.
C
A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include? A. tender to the touch B. reddened C. nonmovable D. located over bony prominence
D
Secondary injuries
cerebral edema, hemorrhage, ischemia, hypoxia, infection, electrolyte imbalances, anemia
Clinical manifestations of Huntington's disease
chorea, difficulty swallowing, intellectual decline to dementia, emotional disturbance
Cardinal signs of brain death
coma, absence of brain stem reflexes, apnea
Clinical Manifestations of Degenerative Disc Disease
herniated disc (pain)
Beta-blockers are used in the treatment of hyperthyroidism to counteract which of the following effects? A. Sympathetic B. Parasympathetic C. Gastrointestinal effects D. Respiratory effects
A
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? A. T6 B. S2 C. L4 D. T10
A
At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. A. Bradycardia B. Hypertension C. Bradypnea D. Hypotension E. Tachycardia
A, B, C
A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply. A. The client who is in the first 15 minutes of receiving 1 unit of PRBCs B. The 55 year-old client with spina bifida C. The client who is scheduled for a repeat CT scan of the abdomen D. The client with an infection who is prescribed intravenous vancomycin E. The client who reports an allergy to peanuts that causes throat swelling
A, B, E
What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. A. Assess the client who is at risk for shock. B. Administer vasoconstrictive medications to clients at risk for shock. C. Administer prophylactic packed red blood cells to clients at risk for shock. D. Administer intravenous fluids. E. Monitor for changes in vital signs.
A, D, E
Surgical removal of the thyroid gland is the treatment of choice for thyroid cancer. During the immediate postoperative period, the nurse knows to evaluate serum levels of __________ to assess for a serious and primary postoperative complication of thyroidectomy. A. Sodium B. Calcium C. Potassium D. Magnesium
B
Which is the most common cause of spinal cord injury (SCI)? A. Falls B. Sports-related injuries C. Motor vehicle crashes D. Acts of violence
C
The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for A. signs and symptoms of cardiac insufficiency. B. signs of relapse. C. signs of improvement in the patient's condition. D. renal complications related to acyclovir therapy.
D
The nursing instructor gives their students an assignment of making a plan of care for a client with Huntington's disease. What would be important for the students to include in the teaching portion of the care plan? A. How to exercise B. How to perform household tasks C. How to take a bath D. How to facilitate tasks such as using both hands to hold a drinking glass
D
What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client? A. Reduced preload. B. Reduced afterload. C. Increased cardiac output. D. Decreased blood pressure.
D
Pharmacologic treatment for ALS
Riluzole (Rilutek)
Spinal shock
Sudden depression of reflex activity below level of spinal injury
Neurogenic shock
loss of function of the autonomic nervous system, vital organs affected; BP, HR, and CO decrease
ALS pathophysiology
loss of motor neurons in the anterior horns of the spinal cord and motor nuclei of the lower brain stem
Signs of increasing ICP
tachycardia, increasing systolic pressure, widening pulse pressure
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Dressing or grooming self-care deficit
B
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate? A. Encourage the client to close his eyes. B. Alternatively patch one eye every 2 hours. C. Turn out the lights in the room. D. Instill artificial tears.
B
A middle-aged female client complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect: A. thyroiditis. B. Graves' disease. C. Hashimoto's thyroiditis. D. multinodular goiter.
B
After a thyroidectomy, the client develops a carpopedal spasm while the nurse is taking a BP reading on the left arm. Which action by the nurse is appropriate? A. Administer a sedative as ordered. B. Administer IV calcium gluconate as ordered. C. Start administering oxygen at 2 L/min via a cannula. D. Administer an oral calcium supplement as ordered.
B
Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers? A. Continuous use of an indwelling catheter B. Meticulous cleanliness C. Avoidance of all lotions and lubricants D. Allowing the client to choose the position of comfort
B
The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of? A. Concussion B. Autonomic dysreflexia C. Spinal shock D. Contusion
B
The client with an inflamed knee scheduled to have an arthrocentesis asks the nurse what the synovial fluid will look like. What is the best response by the nurse? A. The fluid will be clear and pale. B. The fluid will be milky, cloudy, and dark yellow. C. The amount of fluid will be scant in volume. D. The fluid will be straw colored.
B
Which is an appropriate nursing intervention in the care of the client with osteoarthritis? A. Provide an analgesic after exercise B. Encourage weight loss and an increase in aerobic activity C. Assess for gastrointestinal complications associated with COX-2 inhibitors D. Avoid the use of topical analgesics
B Important approaches to pain management; aerobic-walking; should plan to use an analgesic before exercise
A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc? A. Ask the client if there is pain on ambulation. B. Ask if the client can walk. C. Have the client lie on the back and lift the leg, keeping it straight. D. Ask if the client has had a bowel movement.
C
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? A. Sciatic nerve pain B. Herniation C. Paresthesia D. Paralysis
C
A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has? A. Benign B. Primary progressive C. Relapsing-remitting (RR) D. Disabling
C
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? A.An epidural hematoma B. An extradural hematoma C. An intracerebral hematoma D. A subdural hematoma
C
Bell palsy is a disorder of which cranial nerve? A. Trigeminal (V) B. Vestibulocochlear (VIII) C. Facial (VII) D. Vagus (X)
C
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse? A. "Don't worry; your child will be fine." B. "Once Guillain-Barré syndrome progresses to the diaphragm, survival decreases significantly." C. "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." D. "It's too early to give a prognosis."
C
A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? A. Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction B. Ineffective cerebral tissue perfusion related to increased intracranial pressure C. Disturbed thought processes related to brain injury D. Ineffective airway clearance related to brain injury
D
A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers A. A full liquid diet B. Isotonic enteral nutrition every 6 hours C. An infusion of crystalloids at an increased rate of flow D. A continuous infusion of total parenteral nutrition
D
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: A. a positive edrophonium (Tensilon) test. B. Kernig's sign. C. a positive sweat chloride test. D. Brudzinski's sign.
A
When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? A. Decerebrate B. Normal C. Flaccid D. Decorticate
A
Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at A. preventing renal insufficiency. B. controlling seizures and increased intracranial pressure. C. maintaining hemodynamic stability and adequate cardiac output. D. preventing muscular atrophy.
B
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? A. Hypophysectomy B. Application of Halo traction C. Burr holes D. Insertion of Crutchfield tongs
C
The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain? A. "I was sitting at home watching television." B. "I was putting my shoes on." C. "I was brushing my teeth." D. "I was taking a bath."
C
Which is the primary vector of arthropod-borne viral encephalitis in North America? A. Birds B. Spiders C. Mosquitoes D. Ticks
C
A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative care plan, the nurse should include which action? A. Keeping a pillow under the client's knees at all times B. Placing the client in semi-Fowler's position C. Maintaining bed rest for 72 hours after the laminectomy D. Turning the client from side to side, using the logroll technique
D
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? A. Disturbed sensory perception (visual) B. Dressing or grooming self-care deficit C. Impaired verbal communication D. Risk for injury
D
symptoms of autonomic dysreflexia
pounding headache, profuse sweating, nasal congestion, goose bumps, bradycardia, HTN
Acute complications of an SCI
spinal shock, neurogenic shock, venous thromboembolism, autonomic dysreflexia, skin integrity and function
The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? A. Cardiogenic shock B. Tetraplegia C. Spinal shock D. Paraplegia
C
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client A reports a headache. B. reports generalized weakness. C. sleeps for short periods of time. D. vomits.
D
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The health care team is concerned about the complication of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? A. Assess frequent vital signs. B. Reposition frequently. C. Assess for pupillary response frequently. D. Record intake and output.
D
A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse? A. Accept the patient's behavior and do not take it personally. B. Request that the patient be cared for by another nurse. C. Discontinue the bath and resume it later. D. Explain that the client is getting good care.
A
A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP? A. Keep the client's neck in a neutral position (no flexing). B. Avoid sedation. C. Cluster all procedures together. D. Keep the head of the client's bed flat.
A
A client is being admitted to a rehabilitation hospital as a result of the tetraplegia caused a stroke. The client's condition is stable, and after admission the client will begin physical and psychological therapy. An important part of nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention? A. maintain sufficient integument capillary pressure B. provide a change of scenery C. maintain psychological well-being D. passive exercise
A
A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? A. Treatment with antimicrobial prophylaxis as soon as possible B. Admission to the nearest hospital for observation C. No treatment unless the roommate begins to show symptoms D. Bedrest at home for 72 hours
A
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: A. raccoon's eyes and Battle sign. B. nuchal rigidity and Kernig's sign. C. motor loss in the legs that exceeds that in the arms. D. pupillary changes.
A
A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? A. Autonomic dysreflexia B. Thrombophlebitis C. Orthostatic hypotension D. Spinal shock
A
A client with quadriplegia is in spinal shock. What finding should the nurse expect? A. Absence of reflexes along with flaccid extremities B. Positive Babinski's reflex along with spastic extremities C. Hyperreflexia along with spastic extremities D. Spasticity of all four extremities
A
A nurse assesses a client in the health care provider's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)? A. Facial erythema, pericarditis, pleuritis, fever, and weight loss B. Photosensitivity, polyarthralgia, and painful mucous membrane ulcers C. Weight gain, hypervigilance, hypothermia, and edema of the legs D. Hypothermia, weight gain, lethargy, and edema of the arms
A
A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? A. Irrigates the wound to remove debris B. Administers an oral analgesic for pain C. Administers acetaminophen (Tylenol) for headache D. Shaves the hair around the wound
A
In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter? A. Acetylcholine B. Epinephrine C. Norepinephrine D. Dopamine
A
The nurse cares for a client with Huntington disease. What intervention is a priority for safe care? A. Protecting the client from falls B. Measuring electrolytes C. Assessing serum cholesterol D. Range-of-motion exercises
A
The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following? A. Positive Kernig's sign B. Negative Brudzinski's sign C. Positive Romberg sign D. Hyper-alertness
A
The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe? A. Ptosis and diplopia B. Muscle weakness and hyporeflexia of the lower extremities C. Difficulty with urination D. Facial distortion and pain
A
The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis? A. Muscle weakness and hyporeflexia of the lower extremities B. Fever and cough C. Hyporeflexia and skin rash D. Ptosis and muscle weakness of upper extremities
A
The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? A. The client has cerebral spinal fluid (CSF) leaking from the ear. B. The client has ecchymosis in the periorbital region. C. The client has an elevated temperature. D. The client has serous drainage from the nose.
A
The primary function of the thyroid gland includes which of the following? A. Control of cellular metabolic activity B. Facilitation of milk ejection C. Reabsorption of water D. Reduction of plasma level of calcium
A
Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, is manifested by which of the following? A. Tachycardia B. Bulbar weakness C. Blindness D. Inability to swallow
A
When caring for a client with diabetes insipidus, the nurse expects to administer: A. vasopressin. B. furosemide. C. regular insulin. D. 10% dextrose.
A
The most common cause of cholinergic crisis includes which of the following? A. Infection B. Overmedication C. Undermedication D. Compliance with medication
B
The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? A. Position the client in the supine position B. Maintain cerebral perfusion pressure from 50 to 70 mm Hg C. Restrain the client, as indicated D. Administer enemas, as needed
B
The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis? A. 0.9% sodium chloride B. Lactated Ringer's C. Albumin D. Dextran
B
Neurological level of spinal cord injury refers to which of the following? A. The lowest level at which sensory and motor function is normal B. The level of the spinal cord transection C. The highest level at which sensory and motor function is normal D. The best possible level of recovery
A
Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock? A. Septic B. Anaphylactic C. Neurogenic D. Cardiogenic
C
The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction? A. "I will change the vest liner periodically." B. "If a pin becomes detached, I'll notify the surgeon." C. "I can apply powder under the liner to help with sweating." D. "I'll check under the liner for blisters and redness."
C
The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find? A. Increased red blood cell count B. Increased C4 complement C. Elevated erythrocyte sedimentation rate D. Increased albumin levels
C
Which condition occurs when blood collects between the dura mater and arachnoid membrane? A. Intracerebral hemorrhage B. Epidural hematoma C. Extradural hematoma D. Subdural hematoma
D
Which statement(s) reflect nursing interventions for a client with post-polio syndrome? A. The nurse administers antiretroviral agents per order. B. The nurse plans patient activities for evening hours rather then morning hours C. The nurse must avoid the use of heat applications in the treatment of muscle and joint pain D. The nurse provides care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the client
D
A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse? A. Place the patient in a sitting position. B. Call the physician. C. Assess the patient for a full bladder. D. Assess the patient for a fecal impaction.
A
A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose? A. The muscles will become fatigued and the patient will not be able to chew food or swallow pills. B. There should not be a problem, since the medication was only delayed by about 2 hours. C. The patient will go into cardiac arrest. D. The patient will require a double dose prior to lunch.
A
A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: A. Constrict blood vessels in the cardiorespiratory system. B. Decrease heart rate. C. Relax the bronchioles. D. Vasodilate the skeletal muscles.
A
Which nursing intervention is the priority for a client in myasthenic crisis? A. Assessing respiratory effort B. Administering intravenous immunoglobin (IVIG) per orders C. Preparing for plasmapheresis D. Ensuring adequate nutritional support
A
While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivate nurses to offer the best care possible is preventing: A. complications. B. falls. C. choking. D. infection.
A
While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe? A. Facial pain in the areas of the fifth cranial nerve B. Hyporeflexia and weakness of the lower extremities C. Ptosis and diplopia D. Fatigue and depression
A
While snowboarding, a fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? A. concussion B. laceration C. contusion D. skull fracture
A
A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan? A. "Exposure to sunlight will help control skin rashes." B. "There are no activity limitations between flare-ups." C. "Monitor your body temperature." D. "Corticosteroids may be stopped when symptoms are relieved."
C
A nurse suspects that a client has Huntington disease based on which assessment finding? A. Slurred speech B. Disorganized gait C. Chorea D. Dementia
C
What is the priority intervention for a client who has been admitted repeatedly with attacks of gout? A. Assess diet and activity at home B. Place client on bed rest C. Increase fluids D. Insert a Foley catheter
A Clients with gout need to be educated about dietary restrictions in order to prevent repeated attacks. Foods high in purine need to be avoided, and alcohol intake has to be limited. Stressful activities should also be avoided. The nurse should assess to determine what is stimulating the repeated attacks of gout.
Which of the following endocrine disorder causes the patient to have dilutional hyponatremia? A. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) B. Diabetes insipidus (DI) C. Hypothyroidism D. Hyperthyroidism
A Patients diagnosed with SIADH retain water and develop a subsequent sodium deficiency known as dilutional hyponatremia. In DI, there is excessive thirst and large volumes of dilute urine. Patients with DI, hypothyroidism, or hyperthyroidism do not exhibit dilutional hyponatremia
The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? A. Tylenol may be administered for aches. B. Observe for any signs of behavioral changes. C. A light meal may be eaten if desired. D. Follow up with regular physician is encouraged.
B
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? A. Decreased pulse rate, respirations of 20 breaths/minute B. Increased pulse rate, adventitious breath sounds C. Increased pulse rate, respirations of 16 breaths/minute D. Decreased pulse rate, abdominal breathing
B
Which disease includes loss of motor neurons in the anterior horns of the spinal cord and motor nuclei of the lower brain stem? A. Parkinson disease B. Amyotrophic lateral sclerosis C. Alzheimer disease D. Huntington disease
B
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? A. Epidural B. Subdural C. Intracerebral D. Cerebral
B
Nursing assessment findings reveal joint swelling and tenderness and a butterfly rash on the face. The nurse suspects which of the following? A. Ankylosing spondylitis B. Scleroderma C. Fibromyalgia D. Systemic lupus erythematous
D
When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect: A. a blood pressure of 130/70 mm Hg. B. a blood glucose level of 130 mg/dl. C. bradycardia. D. a blood pressure of 176/88 mm Hg.
D