Medsurg midterm
A patient returns to the office after starting statin therapy. Which statement by the patient would indicate the need for further assessment by the nurse? "My face is red and itchy." "I am having trouble walking." "I had a couple of headaches last week." "I am having trouble falling asleep at night."
"I am having trouble walking."
The nurse would use which statement to describe to the patient with coronary artery disease (CAD) how fatty streaks are formed? "Damaged arteries allow platelets to form a thrombus." "Damaged arteries allow lipids to be deposited in the intima." "Infections cause bacteria to move inside the artery wall." "Increased cholesterol intake directly causes plaque formation."
"Damaged arteries allow lipids to be deposited in the intima."
A patient with Atrial fibrillation (AF) suddenly develops shortness of breath, chest pain, hemoptysis, and a feeling of impending doom. The nurse recognizes these symptoms as which complication? 1) increased cardiac output 2) absence of atrial kick 3) pulmonary embolism 4) embolic stroke
3) pulmonary embolism
The nurse is planning care for a client who has a spinal cord injury. The_____the patient with activities of daily living therapist is the member of the interdisciplinary team that assist
Occupational therapist
A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, If noted in the client's laboratory report, should be reported before administering the dose of furosemide?
3.2
Which assessment findings alert the nurse that a patient with a spinal cord injury is experiencing autonomic dysreflexia? Select all that apply. A. Bradycardia B. Headache C. Hypertension D. Nasal stuffiness E. Cold and clammy skin
A. Bradycardia B. Headache C. Hypertension D. Nasal stuffiness
A patient with a spinal cord injury at T3 has a weak cough and is exhibiting labored breathing at a rate of 28 and an arterial blood gas of Po2 of 73. Which interventions might be required til stabilize this patient's respiratory status? (Select All That Apply) A. Perform assisted coughing B. Perform tracheal suctioning C. Perform chest physiotherapy D. Prepare for tracheostomy placement E. Prepare the patient for endotracheal intubation
A. Perform assisted coughing B. Perform tracheal suctioning C. Perform chest physiotherapy
When teaching about the pain associated with sickle cell crisis, it is correct to explain that the pain comes from:
Occlusion of arteries by sickle cell
The nurse should monitor for cardiovascular (CV) complications in patients with spinal cord injuries at which level? Above L1 Above T6 Above C4 Above T10
Above T6
Which nursing action is appropriate for the patient in sickle cell crisis?
Administer O2, administer prescribed narcotics, and force fluids
Why is a CT scan the best diagnostic test for evaluating acute head trauma? Measures cerebral blood flow velocity Useful in detecting small lesions Most sensitive imaging technique Allows for rapid diagnosis and intervention
Allows for rapid diagnosis and intervention
Emergency medical services arrive to try emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time?
Assess for patent airway
The nurse is developing a plan of care for a patient admitted to the hospital with chronic back pain. Which interventions should be included in the plan? Select all that apply. Encourage bed rest Assess patient's pain level Provide a light, soft mattress Offer hot and cold compresses Provide pillows while the patient is sleeping
Assess patient's pain level Offer hot and cold compresses Provide pillows while the patient is sleeping
During assessment of a patient with head trauma, the nurse notes slurred speech and a right sided facial droop. Which action should the nurse take? Select all that apply. Determine the patient's pain level Auscultate the patient's bowel sounds Assess the patient's airway patency Visualize the patient's pupillary response Evaluate the patient's level of consciousness
Assess the patient's airway patency Visualize the patient's pupillary response Evaluate the patient's level of consciousness
The brief sensory experience that occurs prior to the onset of seizure is called
Aura
A nurse is caring for a patient with a low cervical spinal cord injury. When assessing the patient, the nurse notices a blood pressure of 98/54. Why might turning or suctioning this patient result in a cardiac arrest? A. Turning can lead to reduced cardiac output due to gravity's effect on the heart B. Increase in vagal stimulation can lead to cardiac arrhythmia and cardiac arrest C. Suctioning may lead to desaturation and respiratory arrest and then to cardiac arrest D. Pain from turning or suctioning can cause decreased respiratory effort and then cardiac arrest
B. Increase in vagal stimulation can lead to cardiac arrhythmia and cardiac arrest
A 37-year-old male is admitted with a severely abscessed tooth, BP 90/42, HR 136, RR 28, SpO2 90% on room air, temperature 38.7º C. The nurse suspects that the patient has developed sepsis. What is the priority nursing intervention? A. Insert an indwelling urinary catheter. B. Initiate intravenous fluid resuscitation C. Obtain a complete chemistry for laboratory analysis. D. Administer prescribed antibiotics prior to blood cultures.
B. Initiate intravenous fluid resuscitation
What response would be the best response to a client with a new SCI who asks if his current paralysis will be permanent? A. If there is a loss of function at the accident, it is not possible to regain motor functioning. B. There is often a period of spinal shock when it is difficult to determine if the paralysis will be permanent, and when it resolves there can be some regaining of abilities. C. You're experiencing spinal shock now; in three weeks you will regain your functioning when the spinal shock resolves. D. It's best to start trying to accept your limitations; it's unlikely that any improvement can occur.
B. There is often a period of spinal shock when it is difficult to determine if the paralysis will be permanent, and when it resolves there can be some regaining of abilities.
A patient is admitted to the hospital following a motor vehicle accident. The patient has an oval shaped bruise behind the right ear in the mastoid region, a very runny nose, and is unable to move the muscles in the right side of his face. Which skull fracture do these clinical manifestations correspond to? A. Orbital fracture B. Frontal fracture C. Basilar skull fracture D. Posterior fossa fracture
C. Basilar skull fracture
A health care provider tells the patient that she has anemia because her red blood cells are being destroyed faster than they can be made. The patient asks the nurse for more information on the cause of her condition. The nurse provides information to the patient on which type of anemia? A. Thalassemia B. Acute anemia C. Hemolytic anemia D. B12 deficiency anemia
C. Hemolytic anemia
The staff development trainer is preparing orientation materials for new staff hired to care for patients with seizure disorders. Which data are included in this presentation? Select all that apply. A. Absence seizures usually last 1 to 3 hours. B. Atonic seizures are loss of motor tone after a few seconds of clonic activity. C. Myoclonic seizures involve sudden brief, involuntary contractions. D. Tonic seizures are sustained muscle contractions lasting a few seconds to minutes. E. Tonic-clonic seizures include rigidity followed by jerking movements.
C. Myoclonic seizures involve sudden brief, involuntary contractions. D. Tonic seizures are sustained muscle contractions lasting a few seconds to minutes. E. Tonic-clonic seizures include rigidity followed by jerking movements.
The nurse is reviewing the intake forms for a patient with acute low back pain. Which finding is mostlikely related to the cause of the pain? A. Went swimming the previous day B. History of degenerative disc disease (DDD) C. Twisted funny while playing volleyball D. Smokes a half pack of cigarettes per week
C. Twisted funny while playing volleyball
A patient undergoing radiation therapy for breast cancer reports feeling fatigued during normal daily activities. The nurse indicates that the patient may be at risk for anemia due to which physiological effect of cancer treatment? A. Excessive blood loss B. Destruction of red blood cells C Decreased synthesis of hemoglobin D. Decreased number of red blood cell precursors
D. Decreased number of red blood cell precursors
Packed red blood cells have been prescribed to a female patient with a hemoglobin level of 7.6g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the patient's temperature before hanging the blood transfusion and records 100.6 F (38.1C) orally. Which action should the nurse take? A. Begin the transfusion as prescribed. B.Administer an antihistamine and begin the transfusion. C. Administer 2 tablets of acetaminophen and begin the transfusion. D. Delay hanging the blood and notify the primary health care provider (PHCP).
D. Delay hanging the blood and notify the primary health care provider (PHCP).
A patient with non-Hodgkin's lymphoma asks why staging is so important. The accurate response to his question is that staging is done to A. determine if you have favorable histology. B. establish your short- and long-term prognoses. C. properly code your disease for statistical purposes. D. help identify the most effective chemotherapy protocols.
D. help identify the most effective chemotherapy protocols.
Upon assessment, the nurse notices that a patient has bleeding gums. The patient reports increased fatigue, malaise, and "chills." What is the priority nursing intervention? A. Document assessment findings. B. Notify the health care provider of the patient's symptoms. C. Obtain vital signs and administer antipyretic medications. D. Review laboratory analysis for signs and symptoms of bone marrow suppression
D.Review laboratory analysis for signs and symptoms of bone marrow suppression
Which of the following peripheral nerve disorder is being investigated for an association for occurrence after a vaccination, surgical procedure, or stressful event?
Guillian Barre syndrome
A bone marrow biopsy reveals which characteristic finding associated with Acute Myelogenous Leukemia (AML)?
Immature Myloblast
A patient diagnosed with metastasizing cancer has a history of immune thrombocytopenic purpura (ITP) controlled with prednisone. Which information will need to be covered in the education plan for this patient? Information on chemotherapy since some drugs will cause thrombocytopenia The interaction between steroids and chemotherapy since there is a synergistic effect The interaction between steroids and radiation since this is known to cause bleeding in patients Information on radiation therapy since radiation has been associated with hypercoagulable states
Information on chemotherapy since some drugs will cause thrombocytopenia
The nurse is administering IV dexamethasone to a patient with a frontal lobe tumor who reports left upper quadrant pain, nausea and vomiting. Upon assessment, the nurse notes coffee ground emesis and tenderness on palpation. Which provider order would the nurse anticipate? IV protonix PO antibiotics Insert NG tube Obtain hemoccult
Insert NG tube
A medication that helps chemotherapeutic agents cross the blood-brain barrier is.
Mannitol
A new patient with a spinal cord injury at C4 experiences a decrease in blood pressure to 60/44 mm Hg and a drop in heart rate to 48. Which condition would the nurse suspect? Spinal shock Neurogenic shock Autonomic dysreflexia Brown-Séquard syndrome
Neurogenic shock
A patient is receiving a blood transfusion. Which solution does the nurse administer with the blood?
Normal Saline
When observing a patient's gait, the examiner is checking the integrity of the:
Observe the position and movement of the head, trunk, and upper extremity
Why is the heart rate undetermined for a patient in ventricular fibrillation (VF)? QRS interval is irregular. P waves are visible but irregular. Hyperkalemia causes atrial fibrillation. P-to-P intervals and QRS complexes are not measurable.
P-to-P intervals and QRS complexes are not measurable.
Why should the patient with a history of myocardial infarction (MI) be monitored closely when premature ventricular contractions (PVCs) are seen on the electrocardiogram (ECG) strip? PVCs may develop into atrial fibrillation
PVCs may develop into atrial fibrillation
Match the sinus rhythms with the relevant patient signs. Patient reports no clinical signs or symptoms; HR is 80 bpm Patient reports exhaustion and episodes of fainting; HR is 50 bpm Patient reports being in extreme emotional stress; HR is 102 bpm Sinus bradycardia Sinus rhythm Sinus tachycardia
Patient reports no clinical signs or symptoms; HR is 80 bpm: Sinus rhythm Patient reports exhaustion and episodes of fainting; HR is 50 bpm: Sinus bradycardia Patient reports being in extreme emotional stress; HR is 102 bpm: Sinus tachycardia
A patient presents to the clinic with possible immune thrombocytopenic purpura (ITP) due to a rash on the upper legs and arm and is also recovering from a bad case of strep throat. The patient has no significant medical history. The nurse should anticipate which medication will be administered to this patient? Heparin Platelets Antibiotic Prednisone
Prednisone
The nurse is caring for a patient who presents with an actively bleeding head wound. The patient is obtunded, with one fixed pupil. The pulse is thready and respiratory effort is increased. Which provider orders would the nurse anticipate? Select all that apply. Insert urinary catheter Prepare for intubation Insert nasogastric tube Administer intravenous (IV) dextrose 5% Administer intravenous (IV) 0.9% saline
Prepare for intubation Administer intravenous (IV) 0.9% saline
A patient in ventricular fibrillation (VF) is receiving CPR. What is the priority intervention?
Prepare to defibrillate
The nurse is assessing a client scheduled for a lumbar puncture. Which clinical manifestation assessed by the nurse complicates the lumbar puncture procedure?
Restlessness and agitation
Which are the two priority nursing diagnoses for the person undergoing chemotherapy for leukemia?
Risk for infection/ risk for injury
Damage to upper motor neurons will result in:
Spasticity
A secondary brain tumor:
Started somewhere else in the body and spread to the brain.
When assessing a patient with coronary artery disease (CAD), which finding is expected? Swelling in the legs Brisk capillary refill Clear breath sounds Warm, dry, pink skin
Swelling in the legs
Which of the following is the drug of choice for a client diagnosed with an ischemic stroke?
TPA
A patient with rapidly increasing ICP had an emergency craniotomy to relieve the pressure. Now that the patient is stable, which action should the care team perform? Cranioplasty Initiate IV access Ventricular shunt Transport to CT scan
Transport to CT scan
The most significant observations to be reported when monitoring a patient with increased ICP are:
Widened pulse pressure and bradycardia
Which nursing action is appropriate for the patient in sickle cell crisis? a) Start an intravenous site and administer fluids per healthcare provider order. b) Medicate the patient that has pain with an opioid pain medication per healthcare provider order c) Push oral fluids per healthcare provider order. d) Administer oxygen per healthcare provider order.
a) Start an intravenous site and administer fluids per healthcare provider order.
The nurse is teaching a client who has a spinal cord injury how to prevent respiratory problems at home. Which statement indicates that the client correctly understands the teaching? a. "I will use my incentive spirometer every 2 hours while I'm awake." b. "I will not drink thick fluids to prevent choking."c. "I will take cough medicine to prevent excessive coughing." d. "I will position myself on my right side so I don't aspirate."
a. "I will use my incentive spirometer every 2 hours while I'm awake."
The nurse is taking the initial history and vital signs on a patient with fatigue. The nurse notes a regular apical pulse of 130 beats/min. Which contributing factors does the nurse assess for? (select all that apply) a. Anxiety or stress b. Fever c. Hypovolemia d. Anemia or hypoxemia e. Hypothyroidism f. Constipation
a. Anxiety or stress b. Fever c. Hypovolemia d. Anemia or hypoxemia
The Nurse is caring for a patient who has been in a long-term care facility for several months following an spinal cord injury (SCI). The patient has had issues with urinary retention and subsequent overflow incontinence and a bladder retraining program was recently initiated. Which are expected outcomes of the training program? (Select all that Apply) a. Demonstrates a predictable pattern of voiding. b. Is able to independently catheterize himself c. Pours warm water over perineum to stimulate voiding d. Takes bethanechol chloride (Urecholine) 1 hour before voiding e. Is able to empty the bladder completely f. Does not experience a urinary tract infection
a. Demonstrates a predictable pattern of voiding e. Is able to empty the bladder completely f. Does not experience a urinary tract infection
A family member of a client with a hemorrhagic stroke asks about anticoagulant therapy. The nurse explains that anticoagulant therapy for the client: a. Is contraindicated because it will increase bleeding b. May be necessary to prevent pulmonary thrombosis c. Is inadvisable because it may mask signs and symptoms d. Will be started if necessary to enhance cerebral circulation
a. Is contraindicated because it will increase bleeding
The nurse is reviewing preliminary ECG results of a patient admitted for mental status changes. The nurse alerts the health care provider about ST elevation or depression in the patient because it is an indication of which condition? a. Myocardial injury or ischemia b. Ventricular irritability c. Subarachnoid hemorrhage d. Prinzmetal's angina
a. Myocardial injury or ischemia
The nurse is caring for a patient with acute low back pain. Which topics would be included when teaching the patient about management techniques? Select all that apply. Encouraging one week of bed rest a. Safe use of oral opioid medications b. Attending physical therapy sessions c. Information on complementary therapy d. Consulting with a surgeon regarding surgical options
a. Safe use of oral opioid medications b. Attending physical therapy sessions c. Information on complementary therapy
To interrupt seizure activity in the patient with status epilepticus the patient must receive: a. lorazepam (Ativan) IV2. b. oral glucose c. phenytoin (Dilantin) orally d. gabapentin (Neurontin) and lamotrigine (Lamictal)
a. lorazepam (Ativan) IV2.
A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse's first action? a. Palpate the area over the bladder for distention. b. Place the client in the Trendelenburg position. c. Administer oxygen via a nasal cannula. d. Perform bilateral carotid massage
a. palpate the area over the bladder for distension
A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit. Which prescribed medication does the nurse prepare to administer? a. tissue plasminogen activator b. Heparin sodium c. Gabapentin (Neurontin) d. Warfarin (Coumadin)
a. tissue plasminogen activator
The nurse is teachina a client who has a spinal cord injury how to prevent respiratory problems at home. Which statement indicates that the client correctly understands the teaching? a."I will use my incentive spirometer every 2 hours while I'm awake." b."I will not drink thick fluids to prevent choking." c."I will take cough medicine to prevent excessive coughing." d."I will position myself on my right side so I don't aspirate."
a."I will use my incentive spirometer every 2 hours while I'm awake."
The Spinal cord injured patient starts to develop respiratory distress. What action should the nurse take to keep the airway open without compromising the patient's spine further? a) Logroll to side while maintaining neutral alignment. b) Perform the jaw-thrust technique. c) Flex the neck with a wedge pillow. d) Use the chin-lift/head-tilt technique.
b) Perform the jaw-thrust technique.
The nurse is assessing a client who was recently diagnosed with a meningioma. Which statement indicates that the client correctly understands the diagnosis? a. "This is the worst type of brain tumor, and surgery is not an option." b. "My tumor can be removed, but I can still have damage because of pressure in my brain." c. "Even after the surgery, I will need chemotherapy to decrease the spread of the tumor." d. "Radiation is never used on brain tumors because of possible nerve damage."
b. "My tumor can be removed, but I can still have damage because of pressure in my brain."
Which of the following tests does the nurse anticipate will be ordered for a patient to confirm a suspected diagnosis of epilepsy? a. Electrocardiogram (ECG) and positron emission tomography (PET) b. Electroencephalogram (EEG) and computed tomography (CT) c. Lumbar puncture (LP) and magnetic resonance imaging (MRI) d. Complete series of skull x-rays and neuro imaging
b. Electroencephalogram (EEG) and computed tomography (CT)
What should the nurse monitor as an adverse reaction when a client is receiving a platelet aggregation inhibitor such as clopidogrel (Plavix)? a. Nausea b. Epistaxis c. Chest pain d. Elevated temperature
b. Epistaxis
What should the nurse monitor when a client is receiving a platelet aggregation inhibitor such as clopidogrel (Plavix)? a. Nausea b. Epistaxis c. Chest pain d. Elevated temperature
b. Epistaxis
The nurse is caring for a client admitted to the intensive care unit after incurring a basilar skull fracture. Which complication of this injury does the nurse monitor for? a. Aspiration b. Hemorrhagic c. Pulmonary embolus d. Myocardial infarction
b. Hemorrhagic
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time (PT) of 35 seconds. On the basis of the prothrombin time, the nurse anticipates which prescription? a. Adding a dose of heparin sodium b. Holding the next dose of warfarin c. Increasing the next dose of warfarin d. Administering the next dose of warfarin
b. Holding the next dose of warfarin
The nurse writes a diagnosis of impaired elimination for the patient with a spinal cord injury. An essential item of data to know during the planning stage is the: a. Patient's understanding of the injury b. Level at which the spinal cord is injured c. Patient's tendency to develop poikilothermia d. Type of mechanical injury inflicted on the spinal cord
b. Level at which the spinal cord is injured
Meet the Client: Ryan Stapleton is a 20-year-old college student attending school in Colorado away from his home in Arizona. He is playing football with some of his friends in the park. He jumps up in the air to catch the football and is tackled by another player. Ryan flips in midair and feels something pop in his neck as he lands hard on the ground. He does not have any pain, but when he tries to get up, he cannot move his legs or arms Ryan is alert and is talking to his friends. What should Ryan's friends do while waiting for emergency personnel to arrive? a. Help Ryan move his legs and assist him to sit up. b. Place a blanket over Ryan and make sure no one moves him. c. Attempt to stabilize his neck with any type of soft material. d. Carefully put Ryan in the back of a truck with one man holding his neck. e. Ensure that the scene around Ryan is safe and that he is not in any immediate danger.
b. Place a blanket over Ryan and make sure no one moves him. e. Ensure that the scene around Ryan is safe and that he is not in any immediate danger.
The nurse is giving home care instructions to a patient who will be discharged with a halo device. What does the nurse instruct the patient to avoid? (Select all that apply.) a. Going out in the cold b. Swimming or contact sports c. Sexual activity d. Bathing in the bathtub e. Driving
b. Swimming or contact sports e. Driving
Excessive vagal stimulation can result from which activities? select all that apply a. jogging b. carotid sinus massage c. suctioning d. voiding e. valsalva maneuver
b. carotid sinus massage c. suctioning e. valsalva maneuver
Which criterion is necessary for a patient to progress from prehypertension to a diagnosis of hypertension? a.) Profound urinary retention is present b.) Persistent blood pressure above 140/90 mm Hg c.) Single blood pressure reading above 138/89 mm Hg d.) A blood pressure increase in the systolic by 10 mm Hg
b.) Persistent blood pressure above 140/90 mm Hg
The nurse is caring for a client admitted to the intensive care unit after incurring a basilar skullfracture. Which complication of this injury does the nurse monitor for? a.Aspiration b.Hemorrhage c.Pulmonary embolus d.Myocardial infarction
b.Hemorrhage
A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, "Why do I need rehabilitation?" How does the nurse respond? a. "Rehabilitation will reverse any physical deficits caused by the stroke." b. "If you do not have rehabilitation, you may never walk again." c. "Rehabilitation will help you function at the highest level possible." d. "Your doctor knows best and has ordered this treatment for you."
c. "Rehabilitation will help you function at the highest level possible."
The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan? a. "Cut all calluses and corns from your feet as soon as you notice them." b. "Your balance will be steadier if you go barefoot while at home." c. "Use a thermometer to check the temperature of bath water." d. "Avoid using lotion on the feet and legs."
c. "Use a thermometer to check the temperature of bath water."
Which information can an electroencephalogram (EEG) provide about a patient who is having seizures? a. An EEG can show the structural makeup of the brain b. An EEG can examine the vascular structures of the brainl c. An EEG can show the location of abnormal brain activity. d. An EEG can examine the components of cerebral spinal fluid (CSF).
c. An EEG can show the location of abnormal brain activity.
An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that they would like to take an herbal substance to help lower their blood pressure. The nurse should take which action? a. Tell the client that herbal substances are not safe and should never be used. b. Teach the client how to take their blood pressure so that is can be monitored closely c. Encourage the client to discuss the use of an herbal substance with the health care provider d. Tell the client that if they take the herbal substance they will need to have their blood pressure checked frequently
c. Encourage the client to discuss the use of an herbal substance with the health care provider
The nurse is caring for a client who has a vertebral fracture. Which intervention does the nurse implement to prevent deterioration of the client's neurologic status? a. Reorient the client to time, place, and person. b. Administer the Mini-Mental State Examination. c. Immobilize the affected portion of the spinal column. d. Reposition the client every 2 hours
c. Immobilize the affected portion of the spinal column.
The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications? a. Administer prescribed analgesics to promote pain relief. b. Cluster nursing procedures together to avoid fatiguing the client. c. Monitor neurologic and vital signs closely to identify early changes in status. d. Position with the head of the bed flat to enhance cerebral perfusion.
c. Monitor neurologic and vital signs closely to identify early changes in status.
Which determination must be made first in assessing a patient with traumatic brain injury? a. Presence of spinal injury b. Whether the patient is hypotensive c. Presence of a patent airway d. Level of consciousness using the Glasgow coma scale
c. Presence of a patent airway
The nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which action does the nurse implement? a. Massage the reddened areas with a barrier cream. b. Perform hip flexion and extension range-of-motion (ROM) exercises. c. Reposition the client so that the reddened area does not bear weight. d. Ensure that the client sits in a chair at least once each shift.
c. Reposition the client so that the reddened area does not bear weight.
A patient with an adrenal tumor has consistent blood pressure readings of 152/86. Which one of the classifications would this disorder represent? a. High blood pressure b. Primary Hypertension c. Secondary Hypertension d. Isolated Systolic hypertension
c. Secondary Hypertension
The nurse is caring for a patient with a relatively minor head injury after a bump to the head. The nurse has the greatest concern about which symptom? a. Headache b. Nausea and vomiting c. Unequal pupils d. Dizziness
c. Unequal pupils
The nurse is caring for a client who has a vertebral fracture. Which intervention does the nurse implement to prevent deterioration of the client's neurologic status? a.Reorient the client to time, place, and person. b.Administer the Mini-Mental State Examination. c.Immobilize the affected portion of the spinal column. d.Reposition the client every 2 hours
c.Immobilize the affected portion of the spinal column.
A client with new-onset status epilepticus is prescribed phenytoin (Dilantin). After teaching the client about this treatment regimen, the nurse assesses the client's understanding. Which statement indicates that the client understands the teaching? a. "To prevent complications, I will drink at least 2 liters of water daily." b. "This medication will stop me from getting an aura before a seizure." c. "I will not drive a motor vehicle while taking this medication." d. "Even when my seizures stop, I will continue to take this drug."
d. "Even when my seizures stop, I will continue to take this drug."
The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client: a. A client complaining of muscle aches, a headache, and history of seizures b. A client who twisted her ankle when rollerblading and is requesting medication for pain c. A client with a minor laceration on the index finger sustained while cutting an eggplant d. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
d. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern. Which action does the nurse implement to assist in relieving this client's constipation? a. Pouring warm water over the perineum b. Tapping the abdomen from left to right c. Administering daily tap water enemas d. Implementing a consistent daily time for elimination
d. Implementing a consistent daily time for elimination
A patient diagnosed with immune thrombocytopenic purpura (ITP) will be undergoing a splenectomy. A family member asks why this procedure is necessary. Which response by the nurse is appropriate? a. Removal of the spleen will enable the production of ADAMTS13 b. The splenectomy will increase the number of platelets being produced c. This procedure is necessary to correct the chronic splenomegaly d. Removal of the spleen will stop the unwarranted destruction of your platelets
d. Removal of the spleen will stop the unwarranted destruction of your platelets
The neurologic assessment of a client who had a craniotomy includes the Glasgow Coma Scale. What does the nurse evaluate to assess the client's score on the Glasgow Coma Scale? (Select all that apply.)
degree of purposeful movement by the client appropriateness of the clients verbal responses stimulus necessary to cause the clients eyes to open
A 19-year-old is brought to the emergency department with sudden onset of high fever, nuchal rigidity, and vomiting. These signs and symptoms are suggestive of
meningitis
Which statement regarding deep vein thrombosis (DVT) in the patient with a spinal cord injury is true?
nurse shuld assess any signs of internal bleeding and any history of recent surgery, HCP will order to administer Low molecular weight heparin
Which statement regarding deep vein thrombosis in the patient with a spinal cord injury is true?
nurse shuld assess any signs of internal bleeding and any history of recent surgery, HCP will order to administer Low molecular weight heparin.
