MEDSURG EXAM 2

A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure?

"I will perform intermittent self-catheterization every 2 to 3 hrs."

A client is scheduled for a lumbar puncture to rule out bacterial meningitis. She tells the nurse that she is fearful of becoming paralyzed from the needle placement in her spinal column. Which of the following responses should the nurse offer?

"The needle is inserted below the third lumbar vertebra, which is well below the point at which the spinal cord ends."

A nurse is preparing a client for a electromyogram (EMG). Which of the following statements indicates that the client understands the pre-procedure teaching?

"This test will help my doctor know if my nerves are working correctly"

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching?

A TIA can precede an ischemic stroke.

What are the priority nursing interventions 8 hours after an abdominal aortic aneurysm repair?

Administering IV fluids and watching kidney function

Which assessment findings of the left lower extremity would the nurse identify as consistent with arterial occlusion? SATA A. Edematous B. Cold and mottled C. Reports of paresthesia D. Pulse not palpable with Doppler E. Warmer than right lower extremity F. Capillary refill less than 3 seconds

B. Cold and mottled C. Reports of paresthesia D. Pulse not palpable with Doppler

A patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation? SATA A. Drink milk with each meal. B. Eat 20 to 30 g of fiber per day. C. Use an oral laxative every day. D. Limit intake of caffeinated beverages. E. Drink 1800 to 2800 mL of water or juice. F. Establish bowel evacuation time at bedtime.

B. Eat 20 to 30 g of fiber per day. D. Limit intake of caffeinated beverages. E. Drink 1800 to 2800 mL of water or juice.

25-yr-old male patient has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority when planning for rehabilitation? A. Prevent urinary tract infection. B. Encourage him to share his feelings. C. Monitor the patient every 15 minutes. D. Teach him about using the gastrocolic reflex.

B. Encourage him to share his feelings.

The patient had an aortic aneurysm repair 6 hours ago. What priority nursing action will maintain graft patency? A. Assess output for renal dysfunction. B. Use IV fluids to maintain adequate BP. C. Use oral antihypertensives to maintain cardiac output. D. Maintain a low BP to prevent pressure on surgical site.

B. Use IV fluids to maintain adequate BP.

What is the first priority of interprofessional care for a patient with a suspected acute aortic dissection?

Control blood pressure

patient was admitted for possible ruptured aortic aneurysm. Ten minutes later, the nurse notes sinus tachycardia 138 beats/min, blood pressure is palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret the findings? A. Tamponade will soon occur. B. The renal arteries are involved. C. Perfusion to the legs is impaired. D. Bleeding into the abdomen is likely.

D. Bleeding into the abdomen is likely.

A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the provider to save the patient's limb? A. Paralysis B. Cramping C. Paresthesia D. Referred pain

Paresthesia

A patient with a T4 spinal cord injuny has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased cardiac output d. Peripheral vasoconstriction

b. Hypotension

Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Check for bowel impaction C. Elevate the head of the bed D. Administer intravenous hydralazine

A. Urinary catheterization

A nurse is preparing an older adult client who had a transient ischemic attack (TIA) for discharge. The nurse should teach the client to monitor which of the following parameters at home?

Blood pressure

When planning care for a patient with a cervical spinal cord injury (C5), which nursing problem has the highest priority? A. Constipation B. Difficulty coping C. Impaired breathing D. Impaired nutritional status

C. Impaired breathing

A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture?

Clear fluid coming from the nares

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather to test?

Cotton wisps

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?

Elevated protein.

A nurse is caring for a client who had cerebrovascular accident (CVA). The client appears alert and engaged during a visit but does not respond verbally to questions. The nurse should document this as which of the following alterations?

Expressive aphasia

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse suspect?

Lower back discomfort

A nurse is providing discharge teaching to a client who has had a transient ischemic attack (TIA). Which of the following instructions should then nurse include?

Reduce dietary sodium

A patient is seen in the emergency department after diving into the pool and hitting the bottom with a blow to the face that hyperextended the neck and scraped the skin off the nose. The patient reports double vision when looking down. During the neurologic assessment, the nurse finds the patient is unable to abduct either eye. The nurse recognizes this finding is related to a. a basal skull fracture. b. an injury to CN VI on both sides. c. a stiff neck from the hyperextension injury. d. facial swelling from the scrape on the bottom of the pool.

b. an injury to CN VI on both sides.

A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for: a. return of reflexes b. bradycardia with hypoxemia c. effects of sensory deprivation d. fluctuations in body temperature

b. bradycardia with hypoxemia

A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to: a. breathe with respiratory support b. drive a vehicle with hand controls c. ambulate with long-leg braces and crutches d. use a powered device to handle eating utensils

b. drive a vehicle with hand controls

A patient with spinal cord injury has severe neurologic deficits. What is the most likely mechanism of injury for this patient? a. Compression b. Hyperextension c. Flexion-rotation d. Extension-rotation

c. Flexion-rotation

The nurse is caring for a patient with peripheral neuropathy who is scheduled for EMG studies tomorrow morning. The nurse should a. ensure the patient has an empty bladder. b. instruct the patient about the risk for electric shock. c. ensure the patient has no metallic jewelry or metal fragments. d. teach the patient that pain may be experienced during the study.

d. teach the patient that pain may be experienced during the study.

Which assessment findings in a patient with a thoracic spinal cord injury (T4) would alert the nurse to possible autonomic dysreflexia? A. Headache and rising blood pressure B. Irregular respirations and shortness of breath C. Abdominal distention and absence of bowel sounds D. Decreased level of consciousness and hallucinations

A. Headache and rising blood pressure

A nurse is reviewing manifestations of a thoracic aortic aneurysm with a newly hired nurse. Which of the following findings should the nurse include in the discussion? (SATA)

Cough Shortness of breath Altered swallowing

Which person would the nurse identify as having the highest risk for abdominal aortic aneurysm? A. A 70-yr-old man with high cholesterol and hypertension B. A 40-yr-old woman with obesity and metabolic syndrome C. A 60-yr-old man with renal insufficiency who is physically inactive D. A 65-yr-old woman with high homocysteine levels and substance use

A. A 70-yr-old man with high cholesterol and hypertension

The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? A. Keep a wrench close or attached to the vest. B. Use the frame and vest to assist in positioning. C. Clean around the pins using betadine swab sticks. D. Loosen both sides of the vest to provide skin care.

A. Keep a wrench close or attached to the vest.

A nurse is caring for a client who is wearing a halo fixator. Which of the following interventions should the nurse implement? SATA

A. Monitor the client's vital signs every 4 hr B. Monitor the client's pin sites for loosening D. Check the client's skin to ensure the jacket is not applying pressure.

The nurse is admitting a preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) daily. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? A. Vitamin K B. Cobalamin C. Heparin sodium D. Protamine sulfate

A. Vitamin K

A nurse perfoms a neurologic assessment on a client with a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement? A: Dysphagia B: Positive Babinski sign C: Decreased deep tendon reflexes D: Ataxia

A: Dysphagia

A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The client's vital signs are blood pressure 160/98 mmHg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take?

Administer antihypertensive medication for blood pressure.

A patient with critical limb ischemia had peripheral artery bypass surgery to improve circulation. What nursing care should be provided on the first postoperative day? A. Keep patient on bed rest. B. Assist patient to walk several times. C. Have patient sit in the chair several times. D. Place patient on their side with knees flexed.

Assist patient to walk several times.

A postoperative patient asks the nurse why the provider ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is accurate? A. "This medication will help prevent breathing problems after surgery, such as pneumonia." B. "This medication will help lower your blood pressure to a safer level, which is very important after surgery." C. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." D. "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."

C. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal."

The patient with peripheral facial paresis on the left side is diagnosed with Bell's palsy. What should the nurse teach the patient about self-care? SATA A. Use of antiseizure medications B.Preparing for a nerve block to manage pain C. Administration of corticosteroid medications D. Surgery if conservative therapy is not effective E. Dark glasses and artificial tears to protect the eyes F. A facial sling to support the muscles and facilitate eating

C. Administration of corticosteroid medications E. Dark glasses and artificial tears to protect the eyes F. A facial sling to support the muscles and facilitate eating

The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? A. Pain assessment B. Glasgow Coma Scale C. Respiratory assessment D. Musculoskeletal assessment

C. Respiratory assessment

A patient sustained a diffuse axonal injury from a traumatic brain injury. Why are IV fluids being decreased and enteral feedings started? A. Free water should be avoided. B. Sodium restrictions can be managed. C. Dehydration can be better avoided with feedings. D. Malnutrition promotes continued cerebral edema.

D. Malnutrition promotes continued cerebral edema.

A nurse is assessing a client who has a head injury with possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve (CN VIII)?

Dizziness and hearing loss

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain?

Frontal

A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use?

Have the client open his mouth and say "aah"

A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next.

Immobilize the client's cervical spine.

A nurse is caring for an adolescent following a lumbar puncture. Which of the following actions should the nurse take?

Place the adolescent in a supine position

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia.

Report of a headache.

Autonomic Dysreflexia (AD)

Return of reflexes after spinal shock resolved may lead to development of autonomic dysreflexia of the SCI at or above 16 Massive uncompensated cardiovascular reaction mediated by SNS

The nurse is caring for a patient who is admitted after a head injury. When would the nurse obtain most of the data related to the 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

During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 C. T1-2 d. C7-8

a. L1-2

What nursing intervention should be implemented for a patient with increased intracranial pressure (ICP)? A. Monitor fluid and electrolyte status carefully. B. Position the patient in a high Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.

A. Monitor fluid and electrolyte status carefully.

The nurse is caring for a 63-yr-old woman taking prednisone (Deltasone) for Bell's palsy. Which statement by the patient requires correction by the nurse? A. "I can take the medication with food or milk." B. "The medication should be started 1 week after paralysis." C. "I can take acetaminophen with the prescribed medications." D. "Chances of a full recovery are good if I take the medication"

B. "The medication should be started 1 week after paralysis."

The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient has a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as: A. central cord syndrome. B. spinal shock syndrome. C. anterior cord syndrome. D. Brown-Séquard syndrome.

B. spinal shock syndrome.

A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she has bowel incontinence 2 or 3 times each day. Which action should the nurse perform first? A. Insert a rectal stimulant suppository. B. Have the patient to gradually increase intake of high-fiber foods. C. Assess bowel movements for frequency, consistency, and volume. D. Teach the patient to avoid all caffeinated and carbonated beverages.

C. Assess bowel movements for frequency, consistency, and volume.

The provider orders intracranial pressure (ICP) readings every hour for a patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? A. Document the ICP reading in the chart. B. Determine if the patient has a headache. C. Assess the patient's level of consciousness. D. Position the patient with head elevated 60 degrees.

C. Assess the patient's level of consciousness.

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?

Cranial nerve XII

A patient learns about rehabilitation for a spinal cord tumor. Which statement by the patient reflects appropriate understanding of this process? A. "I want to be rehabilitated for my daughter's wedding in 2 weeks." B. "Rehabilitation will be more work done by me alone to try to get better." C. "I will be able to do all my normal activities after I go through rehabilitation." D. "With rehabilitation, I will be able to function at my highest level of wellness."

D. "With rehabilitation, I will be able to function at my highest level of wellness."

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next?

Place the client in a high-fowler's position

A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote the clients safety?

Provide an obstacle-free path for ambulation.

What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for patients with PAD? SATA Ramipril (Altace) Cilostazol (Pletal) Simvastatin (Zocor) Clopidogrel (Plavix) Warfarin (Coumadin) Aspirin (acetylsalicylic acid)

Ramipril (Altace) Simvastatin (Zocor) Clopidogrel (Plavix) Aspirin (acetylsalicylic acid)

A nurse is preparing a client for a lumbar puncture. The client has signed the consent form but tells the nurse that she does not remember what the doctor will do during the procedure. Which of the following actions should the nurse take?

Remind the client that the doctor will insert the needle to get a sample of the fluid from her spine.

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding?

Report of sudden, severe back pain.

The nurse teaches a patient with peripheral arterial disease. The nurse determines that further teaching is needed if the patient makes which statement? a. "I should not use heating pads to warm my feet." b. "I should cut back on my walks if it causes pain in my legs." c. "I will examine my feet every day for any sores or red areas. d. "I can quit smoking if I use nicotine gum and a support group"

b. "I should cut back on my walks if it causes pain in my legs."

How would the nurse assess cranial nerves IlI, IV, and VI? a. Check the patient's gag reflex. b. Test the patient's eye movements. c. Ask the patient to smile and frown. d. Have the patient stick out his tongue.

b. Test the patient's eye movements.

When assessing the muscle strength of an older adult, the nurse cannot compare the findings with those of a younger adult because a. nutrition status is better in young adults. b. muscle tone and strength decrease in older adults. c. muscle strength should be the same for all adults. d. most young adults exercise more than older adults.

b. muscle tone and strength decrease in older adults.

The nurse is caring for a patient who has a spinothalamic tract lesion. Which assessment finding would the nurse expect? a. Cranial nerve dysfunction b. Decreased level of consciousness c. Loss of peripheral sensitivity to pain d. Reduced extremity movement and strength

c. Loss of peripheral sensitivity to pain

During assessment of a patient with a spind cord injury at the level of T2 at the rehabilitation center, which finding would concern the nurse the most? a. A heart rate of 92 b. A reddened area over the patient's coccyx c. Marked perspiration on the patient's face and arms d. A light inspiratory wheeze on auscultation of the lungs

c. Marked perspiration on the patient's face and arms

A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the health care provider. b. check the patient's temperature. c. measure the patient's blood pressure. d. elevate the head of the bed to 90 degrees.

c. measure the patient's blood pressure.