MSII Week 3

A new nurse reports to the nurse preceptor that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. Which response by the experienced nurse is best? a. "Being able to sleep doesn't mean pain doesn't exist." b. "Have you ever experienced any type of pain?" c. "The client should be assessed for drug addiction." d. "You're right; I would put the medication back."

A

A nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. Which response by the charge nurse is best? a. "A multimodal approach is the preferred method of control." b. "Clients are consumers and they demand lots of painmedicine." c. "We are all much more liberal with pain medications now." d. "Pain is so complex it takes different approaches to control it."

A

A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson disease. Which statement would the nurse include as part of the teaching? a. "Allow the client to be as independent as possible with activities." b. "Assist the client with frequent and meticulous oral care." c. "Assess the client's ability to eat and swallow before each meal." d. "Schedule appointments early in the morning to ensure rest in the afternoon."

A

After teaching a client with a high thoracic spinal cord injury, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."

A

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask? a. "Do you live in a crowded residence?" b. "When was your last tetanus vaccination?" c. "Have you had any viral infections recently?" d. "Have you traveled out of the country in the last month?"

A to prevent obtain vaccinations and boosters

A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern? a. Request a prescription for an antispasmodic drug such as baclofen. b. Prepare the client for deep brain stimulation surgery. c. Refer the client to a massage therapist to relax the muscles. d. Consult with the occupational therapist for self-care assistance.

ANS: A Clients who have multiple sclerosis often have muscle spasticity which may be reduced by drug therapy, such as baclofen. While massage and assistance with self-care may be helpful, these interventions are not the most effective and, therefore not the most appropriate in managing muscle spasticity. If drug therapy and other interventions do not help reduce muscle spasms, some clients are candidates for deep brain stimulation as a last resort.

The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is "on the light constantly," asking for more pain medication. When assessing this client's pain, which statement or question by the nurse is most appropriate? a. "Help me understand how pain is affecting you right now." b. "I wish I could do more; is there anything I can get for you?" c. "You cannot have more pain medication for 3 hours." d. "Why do you think the medication is not helping your pain?"

ANS: A A client who is preoccupied with physical symptoms and is "demanding" may have some psychosocial impact from the pain that is not being addressed. The nurse provides the client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nurse wishes he or she could do more is very empathetic, but this response does not attempt to learn more about the pain. Simply telling the client when the next medication is due also does not help the nurse understand the client's situation. "Why" questions are probing and often make clients defensive, plus the client may not have an answer for this question.

A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client's nutritional needs. Which response by the nurse is appropriate? a. "He is NPO until the speech-language pathologist performs a swallowing evaluation." b. "You may give him a full-liquid diet, but please avoid solid foods until he gets stronger." c. "Just be sure to add some thickener in his liquids to prevent choking and aspiration." d. "Be sure to sit him up when you are feeding him to make him feel more natural."

ANS: A Any client who has or is suspected of having a stroke should have nothing by mouth until he or she is evaluated for any swallowing problem by the speech-language pathologist (SLP). If dysphagia is present, the SLP makes specific recommendations for the client's plan of care which all staff members must follow to prevent choking and aspiration/aspiration pneumonia.

A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia but no other medical history except well-controlled hypertension and high cholesterol. The client scores a zero. Which action by the nurse is best? a. Assess physiologic indicators and vital signs. b. Do not give pain medication as no pain is indicated. c. Document the findings and continue to monitor. d. Try a small dose of analgesic medication for pain.

ANS: A Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The hierarchy for assessing pain consists of (1) obtaining a verbal report, which is not possible in this client, (2) consider conditions that might reasonably be painful, (3) observe behaviors, (4) evaluate physiologic indicators, and (5) attempt an analgesic trial. The client is not known to have any conditions that reasonably would cause pain. The nurse would next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean that the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case until the nurse has conducted a full assessment. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness.

A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct? a. "Increased pressure from the tumor can cause seizures." b. "Preventing febrile seizures with a tumor is important." c. "Seizures always occur in clients with brain tumors." d. "This drug is used to sedate with a brain tumor."

ANS: A Brain tumors can lead to seizures as a complication. The nurse would explain this to the spouse. Preventing febrile seizures is not related to a tumor. Seizures are possible but do not always occur in clients with brain tumors. This drug is not used for sedation.

The nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed with Alzheimer's disease. Which statement by the caregiver indicates a need for further teaching? a. "I will avoid communicating with the client to prevent agitation." b. "I should use simple, short sentences and one-step instructions." c. "I can try to use gestures or pictures to communicate with the client." d. "I will limit the number of choices I provide for the client."

ANS: A Communication with the client is important to provide cognitive stimulation. Using short simple sentences, using gestures and pictures, and limiting choices provided for the client will help promote communication.

A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process? a. Cardiac dysrhythmias b. Loss of consciousness c. Nausea and vomiting d. Fever

ANS: A Due to fluid and electrolyte changes that typically occur during the rewarming process, the nurse monitors for cardiac dysrhythmias. The other findings are not common during this process.

The nurse in the outpatient surgery clinic is discussing an upcoming surgical procedure with a client. Which information provided by the nurse is most appropriate for the client's long-term outcome? a. "At least you know that the pain after surgery will diminish quickly." b. "Discuss acceptable pain control after your operation with the surgeon." c. "Opioids often cause nausea, but you won't have to take them for long." d. "The nursing staff will give you pain medication when you ask them for it."

B

A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk for a stroke? a. A 27-year-old heavy-cocaine user. b. A 30-year-old who drinks a beer a day. c. A 40-year-old who uses seasonal antihistamines. d. A 65-year-old who is active and on no medications.

ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this person uses them personally and there is no information that they are abused or used heavily. The 65 year old has only age as a risk factor.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse that this is expected and he or she will have to learn to cope.

ANS: A Personality and behavior often change permanently after head injury. The nurse will explain this to the spouse. Asking the client about his or her behavior isn't useful because the patient probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles his or her concerns and feelings.

A nurse assesses a client who is recovering from an open anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the primary health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders

ANS: A Postoperative swelling can narrow the trachea, cause partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.

A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time? a. Assess the client for hypoglycemia and hypoxia. b. Place the client on his or her side. c. Prepare for administration of a fibrinolytic agent. d. Start a continuous IV heparin sodium infusion.

ANS: A The cause of a sudden decline in level of consciousness may or may not be related to a neurologic health problem. Therefore, the client must be evaluated for other common causes, especially hypoglycemia and hypoxia. Placing the client on his or her side may be helpful to prevent aspiration in case the client experiences vomiting, but the clinical situation does not indicate that the client has nausea or vomiting. Administering either an anticoagulant like heparin or a fibrinolytic agent assumes that the client has an acute ischemic stroke, which has not been confirmed through imaging tests.

A client is admitted with a diagnosis of cerebellar stroke. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform postvoid residuals.

ANS: A The client who has a cerebellar stroke would be expected to have ataxia, an abnormal gait. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

ANS: A, C, D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward, the client states, "I am hungry and want breakfast." What is the nurse's best response? a. "I see you are still hungry. I will get you some toast." b. "You ate your breakfast 30 minutes ago." c. "It appears you are confused this morning." d. "Your family will be here soon. Let's get you dressed."

ANS: A Use of validation therapy with clients who have late-stage Alzheimer disease involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease because reality orientation only increases agitation. The other statements do not validate the client's concerns.

The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and symptoms consistent with this injury. What signs and symptoms does the nurse expect? (Select all that apply.) a. Sensitivity to light and sound b. Reports "feeling foggy" c. Unconscious for an hour after injury d. Elevated temperature e. Widened pulse pressure

ANS: A, B A mild TBI would possibly lead to sensitivity to light and sound and a feeling of mental fogginess. The patient would have been unconscious for less than 30 minutes. An elevated temperature is not related. A widened pulse pressure is indicative of increased intracranial pressure, not a mild TBI.

A nurse assesses a client who is recovering from an open traditional anterior cervical fusion. Which assessment findings would alert the nursing to a complication from this procedure? (Select all that apply.) a. Difficulty swallowing b. Hoarse voice c. Constipation d. Bradycardia e. Hypertension

ANS: A, B Complications of the open traditional anterior cervical discectomy and fusion include dysphagia and hoarseness. Constipation, bradycardia, and hypertension are not complications of this procedure.

The nurse assesses a client who has meningitis. Which sign(s) and symptom(s) would the nurse anticipate? (Select all that apply.) a. Photophobia b. Decreased level of consciousness c. Severe headache d. Fever and chills e. Bradycardia

ANS: A, B, C, D All of the choices except for bradycardia are key features of meningitis. Tachycardia is more likely than bradycardia due to the infectious process and fever.

The nurse is taking a history on an older adult. Which factors would the nurse assess as potential risks for low back pain? (Select all that apply.) a. Scoliosis b. Spinal stenosis c. Hypocalcemia d. Osteoporosis e. Osteoarthritis

ANS: A, B, C, D, E All of these factors place the client at risk for low back pain due to spinal alignment changes, bone loss, or joint degeneration. Bone loss worsens if serum calcium levels are below normal.

The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a stroke for which the nurse would assess for this client? (Select all that apply.) a. Heavy alcohol intake b. Diabetes mellitus c. Elevated cholesterol d. Obesity e. Smoking f. Hypertension

ANS: A, B, C, D, E, F The leading causes of stroke include all of these factors.

Based on the known risk factors for stroke, which health promotion practices would the nurse teach a client to promote heart health and prevent strokes? (Select all that apply.) a. Blood pressure control b. Aspirin use c. Smoking cessation d. Low carbohydrate diet e. Cholesterol management f. Increased red wine consumption

ANS: A, B, C, E

The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.) a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain a SaO2 of 95% or greater. d. Maintain the client in a supine position at all times. e. Avoid clustering care nursing activities and procedures. f. Provide environmental stimulation to improve cognition.

ANS: A, B, C, E These precautions help prevent further increases in ICP. Clustering nursing activities and procedures and providing stimulation can increase ICP and should be avoided.

The nurse is preparing for discharge of a client who had a carotid artery angioplasty with stenting to prevent a stroke. For which signs and symptoms with the nurse teach the family to report to the primary health care provider immediately? (Select all that apply.) a. Muscle weakness b. Hoarseness c. Acute confusion d. Mild neck discomfort e. Severe headache f. Dysphagia

ANS: A, B, C, E, F Muscle weakness, acute confusion, severe headache, and dysphagia are all signs and symptoms that could indicate that a stroke occurred. Hoarseness and severe neck pain and swelling may occur as a result of the interventional radiologic procedure.

The nurse assesses a client who is experiencing a common migraine without an aura. Which assessment finding(s) would the nurse expect? (Select all that apply.) a. Headache lasting up to 72 hours b. Unilateral and pulsating headache c. Abrupt loss of consciousness d. Acute confusion e. Pain worsens with physical activities f. Photophobia

ANS: A, B, E, F A common migraine with an aura is usually accompanied by photophobia, photophobia, unilateral and pulsating pain, and nausea and/or vomiting. These migraines usually last 4 to 72 hours and are aggravated by physical activity. Loss of consciousness and acute confusion are not associated with a common migraine without an aura.

The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) a. Flexed trunk b. Long, extended steps c. Slow movements d. Uncontrolled drooling e. Tachycardia

ANS: A, C, D Key features of Parkinson's disease include a flexed trunk, slow and hesitant steps, bradykinesia, and uncontrolled drooling. Tachycardia is not a key feature of this disease.

A nurse cares for older clients who have traumatic brain injury. What does the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age-group.

ANS: A, C, D Older adults often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes.

A nurse is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.) a. Neuropathic pain sometimes accompanies amputation. b. Nociceptive pain originates from abnormal pain processing. c. Deep somatic pain is pain arising from bone and connective tissues. d. Somatic pain originates from skin and subcutaneous tissues. e. Visceral pain is often diffuse and poorly localized.

ANS: A, C, D, E Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data would the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

ANS: A, C, D, F

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which statement(s) would the nurse include in this education? (Select all that apply.) a. "Participate in an exercise program to strengthen back muscles." b. "Purchase a mattress that allows you to adjust the firmness." c. "Wear flat instead of high-heeled shoes to work each day." d. "Keep your weight within 20% of your ideal body weight." e. "Avoid prolonged standing or sitting, including driving."

ANS: A, C, E Exercise can strengthen back muscles, reducing the incidence of low back pain. Women should avoid wearing high-heeled shoes because they cause misalignment of the back. Prolonged standing and sitting should also be avoided. The other options will not prevent low back pain.

The nurse is caring for a client who has Alzheimer disease. The client's wife states, "I am having trouble managing his behaviors at home." Which questions would the nurse ask to assess potential causes of the client's behavior problems? (Select all that apply.) a. "Does your husband bathe and dress himself independently?" b. "Do you weigh your husband each morning around the same time?" c. "Does his behavior become worse around large crowds?" d. "Does your husband eat healthy foods including fruits and vegetables?" e. "Do you have a clock and calendar in the bedroom and kitchen?"

ANS: A, C, E To minimize behavior problems, the nurse would encourage the patient to be as independent as possible with ADLs, minimize excessive simulation, and assist the patient to remain orientated. The nurse would assess these activities by asking if the patient is independent with bathing and dressing, if behavior worsens around crowds, and if a clock and single-date calendar are readily available. Diet and weight are not related to the management of behavior problems for a patient who has Alzheimer disease.

A nurse teaches the spouse of a client who has Alzheimer's disease. Which statements should the nurse include in this teaching related to caregiver stress reduction? (Select all that apply.) a. "Establish advanced directives early." b. "Trust that family and friends will help." c. "Set aside time each day to be away from the client." d. "Use discipline to correct inappropriate behaviors." e. "Seek respite care periodically for longer periods of time."

ANS: A, C, E To reduce caregiver stress, the spouse should be encouraged to establish advanced directives early, set aside time each day for rest or recreation away from the client, seek respite care periodically for longer periods of time, use humor with the client, and explore alternative care settings and resources. Family and friends may not be available to help. A structured environment will assist the client with AD, but discipline will not correct inappropriate behaviors and not reduce caregiver stress.

A nurse learns the concepts of addiction, tolerance, and dependence. Which information is accurate? (Select all that apply.) a. Addiction is a chronic physiologic disease process. b. Physical dependence and addiction are the same things. c. Pseudoaddiction can result in withdrawal symptoms. d. Tolerance is a normal response to regular opioid use. e. Tolerance is said to occur when opioid effects decrease. f. Physical dependence occurs after repeated doses of an opioid.

ANS: A, D, E, F Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are not the same; dependence occurs with regular administration of analgesics and can result in withdrawal symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.

The nurse is caring for a client in late-stage Alzheimer disease. Which assessment finding(s) will the nurse anticipate? (Select all that apply.) a. Immobile b. Has difficulty driving c. Wandering d. ADL dependent e. Incontinent f. Possible seizures

ANS: A, D, E, F The client with late-stage Alzheimer's disease is totally bedridden and immobile and, therefore, cannot ambulate to wander or drive. The client is incontinent and ADL-dependent.

The nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Have suction equipment with an airway at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Have oxygen administration set at the bedside. e. Maintain the client on strict bed rest. f. Ensure that the client has IV access.

ANS: A, D, F Oxygen and suctioning equipment with an airway must be readily available. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure.

A nurse assesses cerebrospinal fluid leaking onto a client's surgical dressing. What actions would the nurse take? (Select all that apply.) a. Place the client in a flat position. b. Monitor vital signs for hypotension. c. Utilize a bedside commode. d. Assess for abdominal distension. e. Report the leak to the surgeon.

ANS: A, E If cerebrospinal fluid (CSF) is leaking from a surgical wound, the nurse would place the client in a flat position and contact the surgeon for repair of the leak. Hypotension and abdominal distension are not complications of CSF leakage.

A nurse on the medical-surgical unit has received a hand-off report. Which client would the nurse see first? a. Client being discharged later on a complicated analgesia regimen. b. Client with new-onset abdominal pain rated an 8 on a 0-10 scale. c. Postoperative client who received oral opioid analgesia 45 minutes ago. d. Client who has returned from physical therapy and is resting in the recliner.

ANS: B

A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury. What other assessment findings will the nurse anticipate for this client? a. Quadriplegia b. Flaccid bowel c. Spastic bladder d. Tetraparesis

ANS: B A low-level complete spinal cord injury (SCI) is a lower motor neuron injury because the reflect arc is damaged. Therefore, the client would be expected to have paraplegia and a flaccid bowel and bladder. Quadriplegia and tetraparesis are seen in clients with cervical or high thoracic SCIs.

A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse's first action? a. Perform a comprehensive pain assessment. b. Discontinue the infusion of the drug. c. Conduct a neurologic assessment. d. Administer an antihypertensive drug.

ANS: B A severe headache may indicate that the client's blood pressure has markedly increased and, therefore, the drug should be stopped immediately as the first action. The nurse would then perform the appropriate assessments and possibly administer an antihypertensive medication.

A nurse assesses the health history of a client who is prescribed ziconotide for chronic low back pain. Which assessment question would the nurse ask? a. "Are you taking a nonsteroidal anti-inflammatory drug?" b. "Have you been diagnosed with a mental health problem?" c. "Are you able to swallow oral medications?" d. "Do you smoke cigarettes or any illegal drugs?"

ANS: B Clients who have a severe mental health or behavioral health problem would not take ziconotide because the drug can cause psychotic symptoms such as hallucinations. The other questions do not identify a contraindication for this medication.

A nurse teaches a client who is recovering from an open traditional cervical spinal fusion. Which statement would the nurse include in this client's postoperative instructions? a. "Only lift items that are 10 lb (4.5 kg) or less." b. "Wear your neck brace whenever you are out of bed." c. "You must remain in bed for 3 weeks after surgery." d. "You will be prescribed medications to prevent graft rejection."

ANS: B Clients who undergo spinal fusion are fitted with a neck brace that they must wear throughout the healing process whenever they are out of bed. The client should not lift anything more than 10 lb (4.5 kg). The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.

A nurse is caring for a client who received intraspinal analgesia. Which action by the nurse is most important to ensure client safety? a. Assess and record vital signs every 4 hours. b. Instruct the client to report any unrelieved pain. c. Monitor for numbness and tingling in the legs. d. Perform frequent neurologic assessments.

ANS: B Complications from intraspinal anesthesia are rare but can be life-threatening. The nurse would perform frequent neurologic assessments and notify the primary health care provider for abnormal findings. Vital signs are taken every 1 to 2 hours for at least 12 hours. Unreported pain is managed, but this is not a safety concern. Numbness and tingling outside of the surgical site is not normal but can usually be abated by decreasing the opioid dose. The nurse can also keep the client on bed rest, decreasing safety concerns while reporting to the primary health care provider.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor? a. Peripheral edema b. Facial flushing c. Tachycardia d. Fever

ANS: B Fingolimod is an oral immunomodulator that has two common side effects—facial flushing and GI disturbance, such as diarrhea. Peripheral edema, tachycardia, and fever are not common side effects of this drug.

The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" What is the nurse's best response? a. "This is a sign of fatigue. The client would benefit from a daily nap." b. "Engage the client in scheduled activities throughout the day." c. "It sounds like this is difficult for you. I will consult the social worker." d. "The provider can prescribe a mild sedative for restlessness."

ANS: B Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregiver's concern.

The nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate for migraine headaches. Which condition would alert the nurse to withhold the medication and contact the primary health care provider? a. Bronchial asthma b. Heart disease c. Diabetes mellitus d. Rheumatoid arthritis

ANS: B Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with heart disease, hypertension, or Prinzmetal angina. The other conditions would not affect the client's treatment.

The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse's teaching? a. "I will use "yes" and "no" questions when communicating with the client." b. "I will remind the client frequently to not get out of bed without help." c. "I will offer a urinal every hour to the client due to incontinence." d. "I will feed the client slowly using soft or pureed foods."

ANS: B The client who has left-sided weakness has likely had a right-sided stroke in the brain. Clients who have strokes on the right side of the brain tend to be very impulsive and exhibit poor judgment. Therefore, to keep the client safe, the staff will need to remind the client to stay in bed unless he has assistance to prevent falling. There is no evidence in the clinical situation that the client has aphasia (which is less common in those with right-sided strokes), difficulty swallowing, or urinary incontinence.

A client is put on twice-daily acetaminophen for osteoarthritis. Which finding in the client's health history would lead the nurse to consult with the primary health care provider over the choice of medication? a. 25-pack-year smoking history b. Drinking 3 to 5 beers a day c. Previous peptic ulcer d. Taking warfarin

ANS: B The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which would be investigated prior to prescribing chronic acetaminophen. The nurse would relay this information to the primary health care provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes, acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first? a. Assess the client's urinary output. b. Assess the client's serum sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

ANS: B This client has signs and symptoms of hypernatremia, which is a possible complication after craniotomy. The nurse would assess the client's serum sodium level first and then possibly increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. Currently, the client's neurologic examination is normal. About what drug would the nurse plan to teach the patient? a. Alteplase b. Clopidogrel c. Heparin sodium d. Mannitol

ANS: B This client's signs and symptoms are consistent with a transient ischemic attack, and the client would likely be prescribed aspirin or clopidogrel to prevent platelet aggregation on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

A nurse assesses a client who is recovering from the implantation of a vagal nerve-stimulation device. For which signs and symptoms would the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures

ANS: C, D Complications of surgery to implant a vagal nerve-stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures. Bleeding is not a common complication of this procedure, and infection would not occur during the recovery period.

A client is admitted with a confirmed left middle cerebral artery occlusion. Which assessment findings will the nurse expect? (Select all that apply.) a. Ataxia b. Dysphagia c. Aphasia d. Apraxia e. Hemiparesis/hemiplegia f. Ptosis

ANS: B, C, D, E, F All of these assessment findings are common in clients who have a stroke caused by an occlusion of the left middle cerebral artery with the exception of ataxia (most often present in clients who have cerebellar strokes). This artery supplies the majority of the left side of the brain where motor, sensory, speech, and language centers are located.

A nurse plans care for a client with a halo fixator. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Remove the vest for client bathing. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the patient's oral fluid intake. e. Assess the chest and back for skin breakdown.

ANS: B, E The nurse would assess the pin sites for signs of infection or loose pins. The nurse would also assess the client's chest and back for skin breakdown from the halo vest. The vest is not removed for bathing and the pins are not intentionally loosened.

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. Which pain assessment tool would the nurse choose for this assessment? a. Numeric rating scale b. Verbal Descriptor Scale c. FACES Pain Scale-Revised d. Wong-Baker FACES Pain Scale

ANS: C All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults. A confused client with difficulty speaking would not be a good candidate for the numeric rating scale or the verbal descriptor scale. The cartoon images on the Wong-Baker FACES Pain Scale may not be appropriate for an adult client.

A client is admitted with a traumatic brain injury. What is the nurse's priority assessment? a. Complete neurologic assessment b. Comprehensive pain assessment c. Airway and breathing assessment d. Functional assessment

ANS: C Although the client has a brain injury, the most important assessment is to assess the client's ABCs, which includes airway, breathing, and circulation. The other assessments are performed later after the client is stabilized.

The nurse teaches assistive personnel (AP) about how to care for a client with early-stage Alzheimer disease. Which statement would the nurse include? a. "If she is confused, play along and pretend that everything is okay." b. "Remove the clock from her room so that she doesn't get confused." c. "Reorient the client to the day, time, and environment with each contact." d. "Use validation therapy to recognize and acknowledge the client's concerns."

ANS: C Clients who have early-stage Alzheimer disease would be reoriented frequently to person, place, and time. The AP would reorient the client and not encourage the client's delusions. The room would have a clock and whiteboard with the current date written on it. Validation therapy is used with late-stage Alzheimer disease.

The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The daughter asks, "Will the sertraline my mother is taking improve her dementia?" How would the nurse respond to the purpose of the drug? a. "It will allow your mother to live independently for several more years." b. "It is used to halt the advancement of Alzheimer's disease but will not cure it." c. "It will not improve her dementia but can help control emotional responses." d. "It is used to improve short-term memory but will not improve problem solving."

ANS: C Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer disease. However, certain psychoactive drugs may help suppress emotional disturbances and manage depression, psychoses, or anxiety. Drug therapy will not allow the client with middle-stage dementia to safely live independently.

The nurse assesses a client who has a history of migraines. Which symptom would the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue

ANS: C Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other symptoms are not associated with an impending migraine with aura.

The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate. Which statement by the client indicates a need for further teaching? a. "I will rotate injection sites to prevent skin irritation." b. "I need to avoid large crowds and people with infection." c. "I should report any flulike symptoms to my primary health care provider." d. "I will report any signs of infection to my primary health care provider."

ANS: C Glatiramer is given by subcutaneous injection. The first dose is administered under medical supervision, but the nurse teaches the client how to self-administer the medication after the initial dose, reminding the client about the need to rotate injection sites. Like other immunomodulators, this drug can make the client susceptible to infection. However, flulike symptoms occur more commonly with interferons rather than glatiramer.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met? a. Chooses preferred items from the menu. b. Eats 75 to 100% of all meals and snacks. c. Has clear lung sounds on auscultation. d. Gains 2 lb (1 kg) after 1 week.

ANS: C Impaired swallowing can lead to aspiration and then aspiration pneumonia, so the expected outcome for this problem is to experience no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate that the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client? a. Phenytoin b. Lorazepam c. Mannitol d. Morphine

ANS: C Increased intracranial pressure is often the result of cerebral edema as a result of traumatic brain injury. Therefore, as osmotic diuretic such as mannitol or a loop diuretic like furosemide is administered. The other drugs are not appropriate for managing increasing ICP.

A new nurse asks the precepting nurse "What is the best way to assess a client's pain?" Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Client's self-report d. Objective observation

ANS: C Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? a. Initiate oxygen via a nasal cannula. b. Recheck the client's blood pressure. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury such as s stroke. The other actions are not appropriate for this complication.

A registered nurse is caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). Which action by the nurse indicates the need for further education on pain control with PCA? a. Assesses the client's pain level per agency policy. b. Monitors the client's respiratory rate and sedation. c. Presses the button when the client cannot reach it. d. Reinforces client teaching about using the PCA pump.

ANS: C The client is the only person who should press the PCA button. If the client cannot reach it, the nurse would either reposition the client or the button and would not press the button for the client. Pressing the button for the client ("PCA by proxy") indicates the need to review the information about this treatment modality. The other actions are appropriate.

The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke? a. Age greater than or equal to 75 b. Blood pressure greater than or equal to 160/95 c. Unilateral weakness during a TIA d. TIA symptoms lasting less than a minute

ANS: C The client who has a TIA is at risk for a stroke is he or she has one-sided (unilateral) weakness during a TIA. Risk factors also include age greater than or equal to 60, blood pressure greater than or equal to 140/90 (either or both systolic and diastolic), and/or a long duration of TIA symptoms. One minute is not a very long time for symptoms to occur.

A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion. Which complications would the nurse report to the primary health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache

ANS: C, D, E Bulging at the incision site or clear fluid on the dressing after open back surgery strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebrospinal fluid may cause a sudden and severe headache. Pain, redness, and itching at the site are normal.

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the his understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of his injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

ANS: C, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.

The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Which question by the nurse would be best to ask the client for completing a comprehensive pain assessment? a. "Are you worried about addiction to pain pills?" b. "Do you attach any spiritual meaning to pain?" c. "How high would you say your pain tolerance is?" d. "What pain rating would be acceptable to you?"

ANS: D A comprehensive pain assessment includes the items listed in the question plus the client's opinion on a comfort-function outcome, such as what pain rating would be acceptable to him or her. Asking about addiction is not warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged.

The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first? a. Client with amnesia for the incident b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg and on a ventilator d. Client who has a temperature of 102° F (38.9° C)

ANS: D A fever is a poor prognostic indicator in patients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia for the incident are all either expected or positive findings.

The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct about the administration of this drug? a. The recommended time for drug administration is within 90 minutes after admission to the emergency department. b. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. c. The maximum dosage of the drug, including the bolus, is 120 mg intravenously. d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy.

ANS: D Alteplase is thrombolytic which dissolves clots and can cause bleeding as an adverse effect. Clients who are already taking an anticoagulant or antiplatelet agent are at risk for bleeding and therefore they are not candidates for alteplase therapy.

A client diagnosed with Parkinson disease will be starting ropinirole for symptom control. Which statement by the client indicates a need for further teaching? a. "This drug should help decrease my tremors and help me move better." b. "I need to change positions slowly to prevent dizziness or falls." c. "I should take the drug at the same time each day for the best effect." d. "I know the drug will probably make help me prevent constipation."

ANS: D Although ropinirole is a dopamine agonist and mimics dopamine to promote movement, it does not work to prevent constipation. This class of drugs can cause orthostatic hypotension and should be taken at the same time every day.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands the changes associated with this disease? a. "His mask-like face makes it difficult to communicate, so I will use a whiteboard." b. "He should not socialize outside of the house due to uncontrollable drooling." c. "This disease is associated with anxiety causing increased perspiration." d. "He may have trouble chewing, so I will offer bite-sized portions."

ANS: D Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client would be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the client's masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous system's response.

A nurse on the postoperative inpatient unit receives hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client would the nurse see first? a. Client who appears to be sleeping soundly. b. Client with no bolus request in 6 hours. c. Client who is pressing the button every 10 minutes. d. Client with a respiratory rate of 8 breaths/min.

ANS: D Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse would first check this client. The client "sleeping soundly" could be comfortable (no indicators of respiratory distress) and would be checked next. Pressing the button every 10 minutes indicates that the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse would next assess that client's pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.

After teaching a client who is diagnosed with new-onset epilepsy and prescribed phenytoin, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "To prevent complications, I will drink at least 2 L 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."

ANS: D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The drug will not stop an aura before a seizure.

The primary health care provider prescribes donepezil for a client diagnosed with early-stage Alzheimer disease. What teaching about this drug will the nurse provide for the client's family caregiver? a. "Monitor the client's temperature because the drug can cause a low-grade fever." b. "Observe the client for nausea and vomiting to determine drug tolerance." c. "Donepezil will prevent the client's dementia from progressing as usual." d. "Report any client dizziness or falls because the drug can cause bradycardia."

ANS: D Donepezil is a cholinesterase inhibitor that may temporarily slow cognitive decline for some clients but does not alter the course of the disease. The family caregiver would want to monitor the client's heart rate and report any incidence of dizziness or falls because the drug can cause bradycardia. It does not typically cause fever or nausea/vomiting.

The nurse plans care for a client with Parkinson's disease. Which intervention would the nurse include in this client's plan of care? a. Restrain the client to prevent falling. b. Ensure that the client uses incentive spirometry. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater.

ANS: D Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Pursed-lip breathing increases exhalation of carbon dioxide; incentive spirometry expands the lungs. The client should not be restrained to prevent falls. Other less restrictive interventions should be used to maintain client safety.

A nurse receives a hand-off report on a female client who had a left-sided stroke with homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder and bowel retention and/or incontinence. b. Listen to the client's lungs after eating or drinking for diminished breath sounds. c. Support the client's left side when sitting in a chair or in bed. d. Remind the client to move her head from side to side to increase her visual field.

ANS: D Homonymous hemianopsia is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

The nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure? a. Atonic b. Myoclonic c. Absence d. Tonic-clonic

ANS: D Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.

A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. Which intervention for pain management does the nurse include in the client's care plan? a. As-needed pain medication after therapy b. Pain medications prior to therapy only c. Patient-controlled analgesia with a basal rate d. Round-the-clock analgesia with PRN analgesics

ANS: D Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A patient-controlled analgesia pump might be a good idea but needs bolus (intermittent) settings to accomplish adequate pain control, with or without a basal rate. Pain control needs to be continuous, not just administered prior to therapy.

A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate? a. Request a directive from the client's primary health care provider. b. Ask the family if they agree to organ donation for the client. c. Wait until brain death is determined before acting on organ donation. d. Contact the local organ procurement organization as soon as possible.

ANS: D The appropriate nursing action is to respect the client's desire to be an organ donor and contact the local organ procurement organization even if family members do not agree. In most agencies, the primary health care provider does not have to write an order or directive to approve the organ donation. Family consent is not required.

The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client? a. Projectile vomiting b. Dilated and nonreactive pupils c. Severe hypertension d. Decreased level of consciousness

ANS: D The earliest sign of increasing ICP is decreased level of consciousness. The other signs occur later.

The nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

ANS: D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise due to interference with diaphragmatic innervation. The other actions would be performed after airway and breathing are assessed.

After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will wear my medical alert bracelet at all times." b. "While taking my medications, I will not drink any alcoholic beverages." c. "I will tell my doctor about my prescription and over-the-counter medications." d. "If I am nauseated, I will not take my epilepsy medication."

ANS: D The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseated. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the primary health care provider aware of all drugs he or she is taking to prevent complications of polypharmacy.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

ANS: D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

A client continues to have persistent low back pain even after using a number of nonpharmacologic pain management strategies. Which prescribed drug would the nurse anticipate that the client might need to manage the pain? a. Oxycontin b. Gabapentin c. Lorazepam d. Tramadol

ANS: D When nonpharmacologic strategies, including physical therapy, are not effective in managing pain, current standards recommend a mild opioid such as tramadol or serotonin-norepinephrine reuptake inhibitor. Strong opioids such as oxycontin and benzodiazepines such as lorazepam are not considered best practice.

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment would the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves

ANS: D, E Meningococcal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers would wear a surgical mask when within 6 feet (1.8 m) of the client and would continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

A client is scheduled for a percutaneous endoscopic lumbar discectomy. Which statement by Does the client indicate a need for further teaching? a. "I should have a lot less pain after surgery." b. "I'll be in the hospital for 2 to 3 days." c. "I should not have any major surgical complications." d. "I could possibly get an infection after surgery."

B

A client with early-stage Alzheimer's disease is admitted to the hospital with chest pain. Which nursing action is most appropriate to manage this client's dementia? a. Provide animal-assisted therapy as needed. b. Ensure a structured and consistent environment. c. Assist the client with activities of daily living (ADLs). d. Use validation therapy when communicating with the client.

B

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse anticipate preparing for administration? a. Atenolol b. Lorazepam c. Phenytoin d. Lisinopril

B

A nurse is teaching a client who experiences migraine headaches and is prescribed propranolol. Which statement would the nurse include in this clients teaching? a. "Take this drug only when you have symptoms indicating the onset of a migraine headache." b. "Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches." c. "This drug will relieve the pain during the aura phase soon after a headache has started." d. "This drug will have no effect on your heart rate or blood pressure because you are taking it for migraines."

B

A client with a broken arm had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. Which actions by the nurse are most appropriate? (Select all that apply.) a. Ask for a physical therapy consult. b. Educate the client on cold therapy. c. Offer to provide a heating pad. d. Repeat the ice application. e. Teach the client relaxation techniques. f. Offer the client headphones with music.

B, D, E

A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching? a. "Be sure that you use a wheelchair when you go out in public." b. "Wear an undergarment brief at all times in case of incontinence." c. "Avoid overexertion, stress, and extreme temperature if possible." d. "Avoid having sexual intercourse to conserve energy."

C

The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first? a. Start fluids via a large-bore catheter. b. Administer IV push diazepam. c. Turn the client's head to the side. d. Prepare to intubate the client.

C

A nurse is assessing pain in an older adult. Which action by the nurse is best? a. Ask only "yes-or-no" questions so the client doesn't get too tired. b. Give the client a picture of the pain scale and come back later. c. Question the client about new pain only, not normal pain from aging. d. Sit down, ask one question at a time, and allow the client to answer.

D

The nurse is collaborating with the occupational therapist to assist a client with a complete cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid would be most appropriate for the client to meet this outcome? a. Rolling walker b. Quad cane c. Adjustable crutches d. Sliding board

D

The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver? a. "Provide periods of exercise and rest for the client." b. "Place a padded throw rug at the bedside." c. "Provide a highly stimulating environment." d. "Install safety locks on all outside doors."

D

The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? a. Client's symptoms occurred slowly over several hours. b. Client because increasingly lethargic and drowsy. c. Client reported severe headache before other symptoms. d. Client has a long history of atrial fibrillation.

D The major cause of embolic strokes is a history of heart disease, especially atrial fibrillation. Most clients who have an embolic stroke have acute sudden neurologic symptoms but stay alert rather than lethargic. Decreasing level of consciousness and severe headache are more common in clients who have hemorrhagic strokes.