Medsurg 4
The next morning, the nurse notes that the client's heart rate is 48/min and blood pressure is 78/64. His skin is warm and dry. 3. What is the appropriate nursing action? A.Notify the provider immediately. B.Apply oxygen at 2 L per nasal cannula. C.Raise the head of the bed to 45 degrees. D.Increase the rate of IV fluids from 50 to 75 mL/hr.
ANS: A Signs of neurogenic shock include severe bradycardia, warm and dry skin, and severe hypotension. The physician should be notified immediately because this is an emergency. It is best treated by restoring fluids to the circulating blood volume. While increasing the IV rate is a good intervention, going from 50 to 75 mL/hr will not be enough, and a physician's order is needed to make this change.
4. The client's wife calls the health care provider's office to report that her husband took a walk today in a very familiar area, yet got lost and a neighbor brought him home. What safety measure will the nurse recommend? Select all that apply. A."Consider enrollment in the Safe Return program." B."Obtain a medical ID bracelet the he should wear at all times." C."Place him in a geri-chair when you can't be with him." D."Ask the health care provider about a sedative drug to keep him calm." E."Take him for a walk two or three times a day in different neighborhoods."
ANS: A, B, C Positive interventions for coping with restlessness and wandering include having the client wear an ID bracelet, enrolling him in a Safe Return program, and the use of a geri-chair. Physical and chemical restraints such as sedatives should only be used as a last resort. Taking him for walks in different neighborhoods may increase confusion.
A client with a spinal cord injury at C5-C6 becomes flushed and reports a sudden severe headache. Vital signs show a blood pressure of 190/100 mm Hg and heart rate of 50 beats/min. What is the appropriate nursing intervention? A.Notify the health care provider. B.Place the client in a sitting position. C.Check the client for fecal impaction. D.Check the urinary catheter for obstruction.
ANS: B Autonomic dysreflexia is an excessive, uncontrolled sympathetic output and is a neurologic emergency in clients with spinal cord injury T6 and above. The first priority of care is to place the client in a sitting position. Then contact the health care provider to treat the increased blood pressure. The cause of this syndrome is a noxious stimulus—most often a distended bladder or constipation. Rapid treatment is essential to prevent a stroke. All other actions can be taken after placing the client in the sitting position.
1. The wife of a client recently diagnosed with Alzheimer's disease asks the nurse if there is a cure for her husband's illness. What is appropriate nursing response? A."Eating a balanced diet that includes lots of soy products can prevent Alzheimer's disease." B."Cholinesterase inhibitor drugs can slow the progression of the disease for some clients." C."Removal of neuritic plaques can prevent vascular degeneration and improve brain cell function." D."Decreasing the levels of neurotransmitters in the brain can slow the progression of the disease."
ANS: B Cholinesterase inhibitors are approved for treating Alzheimer's disease symptoms. They work to improve cholinergic neurotransmission in the brain by delaying the destruction of acetylcholine (ACh) by the enzyme acetylcholinesterase. This slows the onset of cognitive decline in some clients.
The family of a client with Alzheimer's disease (AD) reports increasing symptoms of paranoia in the client. Which nursing response is appropriate? A."There is often an underlying psychiatric condition with AD." B."Some clients with dementia may experience paranoia, delusions, and even hallucinations." C."This reflects a sign of rapid progression of the AD." D."Remind the client that their paranoia is unfounded."
ANS: B For some clients with dementia, emotional and behavioral problems occur; this does not mean that the client has a psychiatric disorder - it is a byproduct of the cognitive changes associated with AD. They may experience paranoia (suspicious behaviors), delusions, hallucinations, and depression. Document these behaviors, and ensure the client's safety. It will not benefit the client to remind them that the paranoia is unfounded, nor does it reflect a sign of rapid progression of AD.
2. The client is admitted for observation. Upon reassessment an hour later, which finding will the nurse immediately report to the provider? A.Unresolved headache B.Blood pressure of 90/70 mm Hg C.Neck pain remains at "5" on a 0-to-10 scale D.Increase in the Glasgow Coma Scale score
ANS: B Low systolic blood pressure can indicate a decrease in perfusion to the spinal cord, which could worsen the client's condition. A headache may linger. Neck pain is the chief concern, but it is unlikely to resolve completely while in the ED. An increase in the GCS score indicates improvement in a client's condition.
In assessing a client with persistent low back pain, which question will the nurse ask as the priority? A."Are you still going to work?" B."What helps you to manage the pain?" C."Can you describe how the pain feels?" D."Have you ever had an MRI of your back?"
ANS: B Obtaining a thorough assessment of the client's pain level and effective interventions to treat pain is an important element of the nursing assessment. The priority assessment question helps the nurse more fully understand the client's experience with pain, and how the client has attempted to address the pain. All other questions can be asked as follow-ups to the priority question.
At a 6-month follow-up appointment, the wife states that the client occasionally has difficulty finding the correct words to use when communicating. 3. What term does the nurse use to document this assessment data? A.Apraxia B.Aphasia C.Anomia D.Agnosia
ANS: C Anomia is the inability to find words. Apraxia is the inability to use words or objects correctly. Aphasia is the inability to speak or understand. Agnosia is the loss of sensory comprehension
The wife states that her husband is able to perform most of his own ADLs (activities of daily living), and wants to keep him safely and independently functioning in their home as long as possible. 2. To facilitate the client's safe independence, which action will the nurse recommend? A.Ensure that door locks can be easily opened by the client. B.Take the client out often so that he can socialize with many people at once. C.Vary times for meals, bedtime, and getting up in the morning. D.Place outfits on hangers, then allow the client to choose what to wear.
ANS: D Allowing the client to choose what to wear supports the client's independence because he can still dress himself. The other responses are not appropriate strategies for clients with Alzheimer's disease. Crowds of people would further confuse the client. Clients with Alzheimer's disease do much better with a consistent routine. Easily unlocked doors provide easy access in case the client begins wandering
During the call, the wife states that she must go out of town for 3 days to care for an elderly cousin, and she is concerned about her husband's care. 5. Which nursing response is appropriate? A."Can you return home sooner than 3 days?" B."Why are you choosing to care for your cousin instead of your spouse?" C."Your husband only has mild Alzheimer's disease, so staying home alone is acceptable." D."There are organizations that may be able to provide an interim caretaker for your husband."
ANS: D The client has stage II (moderate) Alzheimer's disease, based on his symptoms, and needs supervision. Providing information about organizations that may be able to help care for him is most appropriate. Asking the client's wife to change her travel plans is nontherapeutic and does not address the underlying concern for the client's safety.
A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T 12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should by the nurse's highest priority? Prevention of a.further damage to the spinal cord b.contractures of the lower extremities c.skin breakdown of areas that lack sensation d.postural hypotension when placing the client in a wheelchair
Answer: A The greatest risk to the client during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention the nurse should take is to prevent further minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.
The client has severely increased intracranial pressure. Which diagnostic test would the neurologist avoid performing on this client? A.Magnetic resonance imaging B.Electroencephalography C.Computed tomography with contrast D.Lumbar puncture
Answer: D Rationale: Because of the danger of sudden release of CSF pressure, a lumber puncture is not done for patients with symptoms indicating severely increased intracranial pressure (ICP).
A nurse is caring for a male client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? a.Condom catheter b.Intermittent urinary catheterization c.Crede's method d.Indwelling urinary catheter
Answer: a The nurse should implement the noninvasive use of a condom catheter, because the bladder will empty on its own due to the client having an upper motor neuron injury, which is manifested by a spastic bladder
A nurse is providing discharge instructions to female client who has a prescription for phenytoin. Which of the following information should the nurse include? a.Consider taking oral contraceptives when on this medication. b.Watch for receding gums when taking the medication. c.Take the medication at the same time every day. d.Provide a urine sample to determine therapeutic levels of the medication.
Answer: c The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness, take oral contraceptives because contraceptives effectiveness is decreased, have periodic blood tests to determine the therapeutic level of phenytoin
A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? a.Sit facing the window during the headache. b.Increase physical activity when a headache is present. c.Drink beverages that contain artificial sweeteners to prevent headaches. Apply a cool cloth to the face during a headache
Answer: d A cool clothe placed over the client's eyes provides comfort and can relieve pain
Ten days later the client is scheduled for discharge to a rehabilitation facility. 4. What does the nurse identify as realistic initial priorities of care during rehabilitation?
During rehabilitation, clients learn about self-care, mobility skills, and work on bowel and bladder retraining. A typical stay is 1 to 2 months.
A 33-year-old man is brought to the ED after being hit from behind in a motor vehicle accident. The car that hit him was traveling at 20 mph. He has a cervical immobilizer on, and is alert and oriented. He reports neck pain of a "5" on a 0 to 10 scale, and otherwise appears in no distress. 1. What is the priority nursing assessment for this client? A.Airway B.Circulation C.Sensory perception D.Level of consciousness
ANS: A Even if the client is in no apparent distress, airway must always be assessed first. Circulation, level of consciousness, and sensory perception can be assessed after the airway.
The nurse is caring for a 30-year-old client who experienced a frontal lobe infarction after a motorcycle accident. What is the appropriate nursing intervention? A.Enable the bed alarm safety system. B.Use a picture board to communicate. C.Place all items directly in front of the client. D.Teach to use a call light before getting out of bed.
ANS: A Frontal lobe injuries may interfere with the client's ability to regulate behavior based on judgment and foresight and also may affect reasoning, concentration, and abstraction. The client may not be able to reason through how to use the call light. Enabling the bed alarm is important to reduce fall risk. Placing items in front of the client would be helpful for parietal injuries involving spatial perception deficits, and a communication board would be indicated for an injury to the temporal lobe.
The nurse is caring for an older adult who is usually alert and oriented. When the client become suddenly confused, what is the priority nursing assessment? A.SpO2 B.Temperature C.Drug reconciliation D.Laboratory electrolyte results
ANS: A Many things influence transmission of nerve impulses affecting mental state. In the older adult, a lack of oxygen often causes mental status changes. Therefore SpO2 should be assessed first. Changes in extracellular electrolytes, specifically sodium, can also alter mental status, as can hypnotic, anesthetic, and sedating agents. Confusion or change in mental status such as agitation may also be associated with infection (noted by fever). Certain drugs can cause confusion, as well. These factors can all be assessed after adequate oxygenation is ensured.
When caring for a client with Parkinson disease, the nurse understands that progressive difficulty with which factor is a primary expected outcome? A.Nutrition B.Elimination C.Motor ability D.Effective communication
ANS: C Parkinson disease is a progressive debilitating neurodegenerative disease affecting motor ability. As the disease progresses, the client may experience difficulty with communication, nutrition, ADLs, elimination, and cognition, yet motor ability is the primary function that is impacted.
A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? A.Lower back pain B.Burning sensation on urination C.Frequency of urination D.Fever and change in urine clarity
The correct answer is D. Fever and changes in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign, A client with a spinal cord injury may not experience a burning sensation or urinary frequency.
