N2 final modules

The nurse is about to administer a contrast medium to the client undergoing diagnostic testing. Which question does the nurse first ask the client?

"Are you taking ibuprofen daily The first question the nurse asks is if the client uses Ibuprofen on a daily basis. Ibuprofen is an NSAID, and daily use may place the client's renal function at risk. The client would also be asked about allergies to contrast agents, daily use of Metformin, and any conditions that may compromise kidney function.Inquiring if a client is in pain is always part of nursing assessment but would not be the first question to ask. The nurse would use this opportunity for education to confirm the client knows the reason for the test and take this time to answer any questions. Diagnostic testing involving magnetic resonance imaging, not contrast medium, requires precautions around metal objects.

A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? "Begin a clear liquid diet at least 24 hours before the test." "Do not eat or drink anything for 12 hours before the test." "Give yourself tap water enemas until the fluid returns are clear." "Be sure to take all currently prescribed medications prior to the procedure."

"Begin a clear liquid diet at least 24 hours before the test."

The nurse is teaching a client about the risk factors of restless legs syndrome. Which statement by the client indicates a correct understanding of the nurse's instruction? "Cigarettes and alcohol must be avoided." "I need to exercise my legs before bedtime." "It is important to stay off my feet." "Over-the-counter drugs must not be taken."

"Cigarettes and alcohol must be avoided."

The nurse is instructing a group of overweight clients on the complications of obesity that develop when weight is not controlled through diet and exercise. Which lifestyle changes does the nurse emphasize? Select all that apply. "Begin a weight-training program for building muscle mass." "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." "Eat a variety of foods, especially grain products, vegetables, and fruits." "Engage in moderate physical activity for at least 30 minutes each day." "Foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home." "Liquid dietary supplements can be substituted safely for solid food while attempting to lose weight."

"Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." "Eat a variety of foods, especially grain products, vegetables, and fruits." "Engage in moderate physical activity for at least 30 minutes each day." "Foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home."

A client's spouse expresses concern that the client, who has Guillain-Barré syndrome (GBS), is becoming very depressed and will not leave the house. What is the nurse's best response? "Contact the Guillain-Barré Syndrome Foundation International for resources. Here is their contact information." "Try inviting several people over so the client won't have to go out." "Let your spouse stay alone. Your spouse will get used to it." "This behavior is normal."

"Contact the Guillain-Barré Syndrome Foundation International for resources. Here is their contact information."

The nursing instructor asks a nursing student to compare Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct? "Difficulty chewing may occur in both disorders." "Both are disorders of the autonomic nervous system." "Facial twitching occurs in both disorders." "Both disorders are caused by the herpes simplex virus, which inflames and irritates cranial nerve V."

"Difficulty chewing may occur in both disorders."

A client is scheduled for an electroencephalogram (EEG) in the morning. Which instruction does the nurse give the client?

"Do not take any sedatives 12-24 hours before the test." Before an EEG, the client needs to be instructed not to use sedatives or stimulants for 12-24 hours prior to the test.A client would not fast prior to an EEG as hypoglycemia may alter results. Testing takes place in a quiet room, so music for distraction is not appropriate. Unless the EEG is for sleep disorder diagnosis, the client will not need to be driven home.

The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? Select all that apply. "Do not wear high-heeled shoes." "Keep weight within 50% of ideal body weight." "Begin a regular exercise program." "When lifting something, the back should be straight and the knees bent." "Standing for long periods of time will help to prevent low back pain."

"Do not wear high-heeled shoes." "Begin a regular exercise program." "When lifting something, the back should be straight and the knees bent."

The spouse of the client with Alzheimer's disease is listening to the home health nurse explain the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." "Memantine (Namenda) is indicated for treatment of early symptoms of Alzheimer's disease. "Rivastigmine (Exelon) is used to treat depression." "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."

"Donepezil (Aricept) will treat the symptoms of Alzheimer's disease."

The nurse's friend fears that something is wrong with his grandmother, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? "Have you taken her for a check-up?" "She has Alzheimer's disease." "That is a normal part of aging." "You should look into respite care."

"Have you taken her for a check-up?

A client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching? "It is important to post my medicine schedule at home, so my family knows my schedule." "I can continue to take over-the-counter drugs like before." "An extra supply of medicine must be kept in my car." "Wearing a watch with an alarm will remind me to take my medicine."

"I can continue to take over-the-counter drugs like before."

A client is being discharged with a prescription for propylthiouracil (PTU). Which statement by the client indicates a need for further teaching by the nurse? "I can return to my job at the day care center." "I must call the primary health care provider if my urine is dark." "I must faithfully take the drug every 8 hours." "I need to report weight gain."

"I can return to my job at the day care center."

The nurse is teaching a client, newly diagnosed with migraines, about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? "I can still eat Chinese food." "I must not miss meals." "It is okay to drink a few wine coolers." "I need to use fake sugar in my coffee."

"I must not miss meals."

A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? "Birth control is not needed while taking sumatriptan." "I must report any chest pain right away." "St. John's wort can also be taken to help my symptoms." "Sumatriptan can be taken as a last resort."

"I must report any chest pain right away."

An older client presents to the clinic after a ground level fall at home. What statement by the client indicates the need for more injury prevention education?

"I only eat little snacks so I don't gain weight." More fall injury prevention education is needed when the client says that he/she will only eat little snacks to prevent weight gain. The brain is sensitive to decreased glucose levels which can lead to falls. This is especially noted in older clients.Taking medication as directed, ensuring adequate hydration, nutrition, and sleep help promote nervous system health and decrease the risk for falls in the elderly.

A client with myasthenia gravis (MG) is receiving cholinesterase inhibitor drugs to improve muscle strength. The nurse is educating the family about this therapy. Which statement by a family member indicates a correct understanding of the nurse's instruction? "I will call 911 if a sudden increase in weakness occurs." "I will increase the dose if a sudden increase in weakness occurs." "The medication must be taken with a large meal." "The medication must be taken on an empty stomach."

"I will call 911 if a sudden increase in weakness occurs."

The nurse is educating a group of older adults about screening for colorectal cancer. Which statement by a group member indicates the need for further clarification about these guidelines? "A barium enema every 5 years is a screening option." "I will need to have a routine colonoscopy every 5 years." "My routine flexible sigmoidoscopy every 5 years is OK." "The 'virtual' colonoscopy every 5 years is acceptable."

"I will need to have a routine colonoscopy every 5 years."

A client with thyroid cancer has just received 131I ablative therapy. Which statement by the client indicates a need for further teaching? "I cannot share my toothpaste with anyone." "I must flush the toilet three times after I use it." "I need to wash my clothes separately from everyone else's clothes." "I'm ready to hold my newborn grandson now."

"I'm ready to hold my newborn grandson now."

The nurse is teaching a client about thyroid replacement therapy. Which statement by the client indicates a need for further teaching? "I will have more energy with this medication." "I will take the medication every morning." "If I continue to lose weight, I may need an increased dose." "If I gain weight and feel tired, I may need an increased dose."

"If I continue to lose weight, I may need an increased dose."

An obese client is prescribed orlistat (Xenical). The client asks the nurse how the drug works. How does the nurse respond? "It decreases the amount of norepinephrine in your brain. This action will increase your feeling of being satisfied on less food." "It increases the amount of serotonin in your brain. This action will greatly increase your metabolic rate, and you will burn calories quicker." "It inhibits enzymes and changes the way your body digests fats. Because fats are only partially digested and absorbed, calorie intake is decreased." "It will alter the chemistry of your brain. Consequently, you will feel full before you overeat."

"It inhibits enzymes and changes the way your body digests fats. Because fats are only partially digested and absorbed, calorie intake is decreased."

A client has been diagnosed with Primary Progressive MS (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates the need for more teaching? "I can alternate wearing my eye patch between eyes for double vision." "I should keep my home clutter free so I don't fall." "It's important I work out in the afternoon so my muscles are warmed up." "I always keep my medications in the same place."

"It's important I work out in the afternoon so my muscles are warmed up."

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? "Avoid using a pillow under the head while sleeping." "Begin driving 1 week after discharge." "Keep straws available for drinking fluids." "Swimming is recommended to keep active."

"Keep straws available for drinking fluids."

The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? "Can't you take care of your spouse?" "Establishing goals and a daily plan can help." "Make sure you take some time off and take care of yourself too." "That's not a very nice thing to say."

"Make sure you take some time off and take care of yourself too."

The nurse is teaching a middle-aged adult client with a body mass index (BMI) of 27.5 and a height of 5'2" (157.5 cm) about what the BMI number means, and about malnutrition. Which client statement indicates a need for further instruction? "If I could get my BMI below 25, my risk for malnutrition would decrease." "I realize that this means that I have some increased health risks." "My goal should be to get my BMI below 18.5." "This means that I have an increased amount of total fat stored in my body."

"My goal should be to get my BMI below 18.5."

A client with new-onset Bell's palsy is being dismissed from the hospital. Which statement made by the client demonstrates a need for further teaching by the nurse? "I'll need artificial tears at least four times a day." "I will eat a soft diet." "My eye must be taped or patched at bedtime." "Narcotics will be needed for pain relief."

"Narcotics will be needed for pain relief."

The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? "I will die early." "I will have gradual deterioration with no healthy times." "Parts of my nervous system have plaques." "This was caused by getting too many x-rays as a child."

"Parts of my nervous system have plaques."

A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? "Every injury is different, and it is too soon to have any real answers right now." "Only time will tell." "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." "Please request a meeting with the health care provider. I will help set that up."

"Please request a meeting with the health care provider. I will help set that up."

A female client is concerned that her inability to conceive a child is connected to her morbid obesity. How does the nurse respond? "Do you feel that your obesity is keeping you from getting pregnant?" "Have you considered adoption as an option?" "Tell me about any changes in your menstrual cycle each month." "What has your health care provider told you about your problems in getting pregnant?"

"Tell me about any changes in your menstrual cycle each month."

The nurse is performing a health assessment on an obese client who states, "I have tried many diets in an effort to lose weight, but have been unsuccessful." How does the nurse assess whether the client's response to stress is related to the client's obesity? "Do you have a history of mental problems, especially depression?" "Do you usually use alcohol or drugs when you feel stressed?" "Tell me what you do to relieve stress in your daily life." "What is it about your obesity that causes you to feel uncomfortable?"

"Tell me what you do to relieve stress in your daily life."

Family members of a client diagnosed with hyperthyroidism are alarmed at the client's frequent mood swings. What is the nurse's best response? "Do the client's mood swings make you feel angry?" "The mood swings would diminish with treatment." "The medications will make the mood swings disappear completely." "Your family member is sick. You must be client."

"The mood swings would diminish with treatment."

The nurse is teaching a class of older adults in the community about engaging in "regular" exercise. What does the nurse advise them? "One to two hours of cardiovascular exercise every day is a good idea." "Joining a fitness program or gym will help greatly with your exercise." "Walking 30 to 40 minutes provides the same benefit as long periods of exercise." "You will benefit most if you get into a group that shares your exercise goals."

"Walking 30 to 40 minutes provides the same benefit as long periods of exercise."

The outpatient clinic nurse is caring for a recovering client who had a colonoscopy. The client asks for a drink. How does the nurse respond to this request? "After I hear bowel sounds, you can have a drink." "Twenty minutes after the procedure was completed, you may have some liquids." "When you are able to pass flatus (gas), you can have a drink." "You can have fluids when you get home and are settled."

"When you are able to pass flatus (gas), you can have a drink."

A client is taking methimazole (Tapazole) for hyperthyroidism and would like to know how soon this medication will begin working. What is the nurse's best response? "You will see effects of this medication immediately." "You will see effects of this medication within 1 week." "You will see full effects from this medication within 1 to 2 days." "You will see some effects of this medication within 2 weeks."

"You will see some effects of this medication within 2 weeks."

Which serum albumin level does the nurse expect to see in a healthy, ambulatory adult client? 2.3 g/dL (23 g/L) 3.7 g/dL (37 g/L) 5.1 g/dL (51 g/L) 5.8 g/dL (58 g/L)

3.7 g/dL (37 g/L)

The RN who usually works on the pediatric unit is floated to the GI medical-surgical unit. Which client is most appropriate for the charge nurse to assign to the float nurse? A 20-year-old with anorexia nervosa receiving total parenteral nutrition through a central venous line A 35-year-old who had a laparoscopic gastroplasty yesterday and is now taking sips of clear liquids A 60-year-old with gastric cancer receiving elemental feedings through a jejunostomy tube A 65-year-old with morbid obesity who requires a preoperative bariatric surgery assessment

A 20-year-old with anorexia nervosa receiving total parenteral nutrition through a central venous line

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis A 36-year-old who needs teaching about an endoscopic retrograde cholangiopancreatography A 40-year-old who will need administration of IV midazolam hydrochloride (Versed) during an upper endoscopy A 46-year-old who was recently admitted with abdominal cramping and diarrhea of unknown causes

A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis

Which morbidly obese client is the least likely candidate for bariatric surgery? A 34-year-old woman experiencing mental confusion A 44-year-old man with a history of hypertension A 50-year-old woman with a history of sleep apnea A 52-year-old man with a history of type 1 diabetes mellitus

A 34-year-old woman experiencing mental confusion

Which client on the medical-surgical unit does the charge nurse assign to the LPN/LVN? A 28-year-old with morbid obesity who had bariatric surgery today A 30-year-old recently admitted with severe diarrhea and Clostridium difficile infection A 36-year-old whose family needs instruction about how to use a gastric feeding tube A 39-year-old with a jejunal feeding tube who needs elemental feedings administered

A 39-year-old with a jejunal feeding tube who needs elemental feedings administered

Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic? A 38-year-old who needs discharge instructions after having an endoscopic retrograde cholangiopancreatography (ERCP) A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy A 43-year-old recently admitted with nausea, abdominal pain, and abdominal distention A 50-year-old with epigastric pain who needs conscious sedation during a scheduled endoscopy procedure

A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy

While working in the outpatient procedure unit, the RN is assigned to these clients. Which client does the nurse assess first? A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) A 54-year-old who is ready for discharge following a colonoscopy A 58-year-old who has just arrived for basal gastric secretion and gastric acid stimulation testing A 60-year-old with questions about an endoscopic ultrasound examination

A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP)

An RN receives the change-of-shift report about these four clients. Which client does the nurse assess first? A 30-year-old admitted 2 hours ago with malnutrition associated with malabsorption syndrome A 45-year-old who had gastric bypass surgery and is reporting severe incisional pain A 50-year-old receiving total parenteral nutrition (TPN) with a blood glucose (BG) level of 300 mg/dL (16.7 mmol/L) A 75-year-old with dementia who is receiving nasogastric feedings and has a respiratory rate of 38 breaths/min

A 75-year-old with dementia who is receiving nasogastric feedings and has a respiratory rate of 38 breaths/min

A client is being evaluated for signs associated with myasthenic crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis? Abdominal cramps, blurred vision, facial muscle twitching Bowel and bladder incontinence, pallor, cyanosis Increased pulse, anoxia, decreased urine output Restlessness, increased salivation and tearing, dyspnea

Abdominal cramps, blurred vision, facial muscle twitching

A client newly diagnosed with Parkinson disease (PD) is being discharged. Which instruction is best for the nurse to provide to the client's spouse? Administer medications promptly on schedule to maintain therapeutic drug levels. Complete activities of daily living for the client. Provide high-fiber, high-carbohydrate foods. Speak loudly for better understanding.

Administer medications promptly on schedule to maintain therapeutic drug levels

A client with trigeminal neuralgia is admitted for a percutaneous stereotactic rhizotomy in the morning. The client currently reports pain. What does the nurse do next? Administers pain medication as requested Ensures that the client has nothing by mouth (NPO) Ensures that the preoperative laboratory work is complete Performs a preoperative assessment

Administers pain medication as requested

Which client will the neurologic unit charge nurse assign to a registered nurse who has floated from the labor/delivery unit for the shift?

Adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes. The charge nurse would assign an RN with experience in labor and delivery to check vital signs and limbs on a client who just returned from a cerebral angiogram. This float nurse would also be able to recognize signs of bleeding.The older adult admitted with a stroke, the young adult post lumbar puncture, and the middle-aged client with a possible brain tumor all require a nurse with more experience with neurologic diagnoses and diagnostic procedures.

The nurse is teaching a group of adults in the community about the 2015-2020 Dietary Guidelines for Americans. What does the nurse emphasize as a dietary strategy suggested in these guidelines? Half of each meal should consist of dairy, fruits, and proteins. Adults should focus on variety and nutrient density and not calories. Older adults should consider lacto-ovarian diets for improved health. Adults should include a multivitamin with iron and vitamin B12 in their diet.

Adults should focus on variety and nutrient density and not calories.

A client presents to the clinic with a migraine and is lying in a darkened room with a wet cloth on the head after receiving treatment. In preparation for dismissal home, what does the nurse do next? Allow the client to remain undisturbed. Assess the client's vital signs. Remove the cloth because it can harbor microorganisms. Turn on the lights for a neurologic assessment.

Allow the client to remain undisturbed.

The wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress? Arranges for respite care Provides positive reinforcement and support to the wife Restrains the client for a short time each day, to allow the wife to rest Teaches the client improved self-care

Arranges for respite care

A client receiving methimazole (Tapazole) calls the home health nurse and mentions that his heart rate is slower than usual. What is the nurse's best response? Advise the client to go to a calming environment. Ask whether the client has increased cold sensitivity or weight gain. Instruct the client to see his primary health care provider immediately. Tell the client to check his pulse again and call back later.

Ask whether the client has increased cold sensitivity or weight gain.

The nurse is assessing an alert client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. (p. 17) Auscultating bowel sounds in all abdominal quadrants Counting the number of bowel sounds in each abdominal quadrant over one minute. Observing the abdomen for symmetry and distention

Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. (p. 17)

A client returns to the neurosurgical floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? Administer pain medication. Assess airway and breathing. Assist with ambulation. Check the client's ability to void.

Assess airway and breathing.

The nurse reviews the vital signs of a client diagnosed with Graves' disease and notes that the client's temperature is 99.6°F (37.6°C). After notifying the primary health care provider, what does the nurse do next? Administers acetaminophen Alerts the Rapid Response Team Asks any visitors to leave Assesses the client's cardiac status

Assesses the client's cardiac status

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? Assessing neurologic status at least every 2-4 hours Decreasing environmental stimuli Managing pain through drug and nondrug methods Strict monitoring of hourly intake and output

Assessing neurologic status at least every 2-4 hours

A client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care? Assigning a case manager Ensuring that all family questions are answered before discharge Providing a safe environment Referring the family to the Alzheimer's Association

Assigning a case manager

An older client is at risk for malnutrition. Which nursing intervention is most appropriate to ensure optimum nutritional intake? Administering antiemetics and analgesics after meals Assisting the client with toileting and oral care prior to meals Turning on the television during meals to provide distraction Reminding UAPs to allow the client to remain in bed during meals

Assisting the client with toileting and oral care prior to meals

The nurse is caring for a client with advanced Alzheimer's disease. Which communication technique is best to use with this client? Assuming that the client is not totally confused Providing the client with several options to choose from Waiting for the client to express a need Writing down instructions for the client

Assuming that the client is not totally confused

Which task does the nurse plan to delegate to the unlicensed assistive personnel (UAP) caring for a group of clients in the neurosurgical unit?

Attend to the care needs of a client who has had a transcranial Doppler study The nurse delegates the UAP to care for the client who has had a transcranial Doppler study. Since transcranial Doppler studies are noninvasive and do not require any postprocedure monitoring or care the UAP can safely attend to this client.Assisting the primary care provider in performing a lumbar puncture and preparing a client for a cerebral arteriogram require assessments and interventions that would be done by licensed nursing staff. Client teaching would also be provided by licensed nursing staff.

How does the nurse accurately calculate a client's body mass index (BMI)? BMI = weight (kg)/height (in meters)2 BMI = weight (lb)/height (in inches)2 BMI = weight (kg)/height (in meters) BMI = weight (lb)/height (in meters)

BMI = weight (kg)/height (in meters)2 The correct formula to accurately calculate a client's body mass index (BMI) is: BMI = weight (kg)/height (in meters)2.

The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for prevention of migraines. The nurse plans to contact the primary care provider (PCP) if the client has which condition? Bipolar disorder Diabetes mellitus Glaucoma Hypothyroidism

Bipolar disorder

A client has just returned from cerebral angiography. Which symptom does the client display that causes the nurse to act immediately?

Bleeding After a cerebral angiography, the nurse would immediately react if the client had any bleeding. If bleeding is present at the puncture site, manual pressure on the site is maintained along with immediate notification of the primary care provider.Increased temperature or the urge to void are not typical complications of cerebral angiography. Severe headache is a typical complication of a lumbar puncture, but not of cerebral angiography.

The nurse encourages a ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique? Blinking for "yes" or "no" Moving lips to speak Using sign language Using a laptop to write

Blinking for "yes" or "no"

The nurse is preparing the room for the client returning from a thyroidectomy. Which items are important for the nurse to have available for this client? Select all that apply. Calcium gluconate Emergency tracheotomy kit Furosemide (Lasix) Hypertonic saline Oxygen Suction

Calcium gluconate Emergency tracheotomy kit Oxygen Suction

The nurse is caring for a client who is scheduled to have a transcranial Doppler (TCD). What does this diagnostic test evaluate?

Cerebral vasospasm A transcranial Doppler (TCD) is used to evaluate cerebral vasospasm or narrowing of arteries. It is noninvasive.Cerebrospinal fluid is obtained and measured during a lumbar puncture (LP). Evoked potentials measure the electrical signals in the brain during an EEG. Intracranial pressure is a measurement of blood, brain tissue, and cerebral spinal fluid and is not measured by TCD.

A client has a primary problem of inadequate nutrition caused by the effects of chemotherapy. The client is receiving continuous enteral feedings through a nasogastric (NG) tube. What does the RN ask the LPN/LVN to do for this client? Assess nutritional parameters on the client every 3 days. Check the residual volume of the NG tube every 4 hours. Monitor the client for signs and symptoms of pneumonia. Teach the client about the purpose of enteral feedings.

Check the residual volume of the NG tube every 4 hours.

A client is admitted into the emergency department (ED) with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? Classic migraine Meningitis Stroke West Nile virus

Classic migraine

The nurse has just received report on a group of clients. Which client does the nurse assess first?

Client who had a cerebral arteriogram and has a cool, pale leg The nurse first assesses the client with a cool, pale leg after an arteriogram. This assessment finding could indicate clot formation at the catheter insertion site and loss of blood flow to the extremity.The client with a GCS of 14, the client with a headache following a lumbar puncture, and the client with expressive aphasia need to be assessed as soon as possible.

The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority?

Client whose Glasgow Coma Scale (GCS) has changed from 15 to 13. After receiving report on a group of clients, the nurse's first priority is to assess the client whose GCS has changed from 15 to 13. A decrease of 2 or more points in the Glasgow Coma Scale total is clinically significant and indicates a major change in neurologic status. This finding must be reported immediately to the primary health care provider (PHCP).The client with hyperactive reflexes, the client displaying plantar flexion when the bottom of the foot is stroked, and the client with decortication upon stimulation will need to be assessed, but they do not require immediate attention.

The nurse manager for the medical-surgical unit is making staff assignments. Which client will be most appropriate to assign to a newly graduated RN who has completed a 6-week unit orientation? Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily Client with follicular thyroid cancer who has vocal hoarseness and difficulty swallowing Client with Graves' disease who is experiencing increasing anxiety and diaphoresis Client with hyperparathyroidism who has just arrived on the unit after a parathyroidectomy

Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily

An RN and LPN/LVN are caring for a group of clients on the medical-surgical unit. Which client will be the best to assign to the LPN/LVN? Client with Graves' disease who needs discharge teaching after a total thyroidectomy Client with hyperparathyroidism who is just being admitted for a parathyroidectomy Client with type 2 diabetes who requires insulin while receiving prednisone (Deltasone) Newly diagnosed client with hypothyroidism who needs education about the use of thyroid supplements

Client with type 2 diabetes who requires insulin while receiving prednisone (Deltasone)

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? Cloudy, turbid CSF Decreased white blood cells Decreased protein Increased glucose

Cloudy, turbid CSF Cloudy, turbid CSF indicates to the nurse that the client may have bacterial meningitis.Clear fluid is a sign of viral meningitis. Increased white blood cells, increased protein, and decreased glucose are signs of bacterial meningitis

The nurse prepares to assess a client with diabetes mellitus for sensory loss. Which equipment is the best choice for the nurse use to perform this assessment?

Cotton-tipped applicator A cotton-tipped applicator is the nurse's best choice to assess sensory loss on a client with diabetes mellitus. Sensory loss is assessed with any sharp or dull object, such as a cotton-tipped applicator. The client indicates whether the touch is sharp or dull. The soft and hard ends of the applicator would be interchanged at random so that the client does not anticipate the next type of sensation.A glucometer tests blood sugar. A hammer tests tendon reflexes. Although a safety pin could be used to test for sensory loss, a cotton-tipped applicator is safer in the event the client is taking anticoagulants.

The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age?

Decreased coordination When performing a neurologic assessment on an elderly client, the nurse expects to find decreased coordination. Older adults experience decreased coordination as a result of the aging process.Older adults frequently go to bed earlier and arise earlier than younger adults. Sensation to touch is decreased not increased. Nightly confusion, sometimes referred to as "sundowning," is not an expected change with all older adults.

What is a common gastrointestinal problem that older adults experience more frequently as they age? Decreased hydrochloric acid levels Excess lipase production Increased liver size Increased peristalsis

Decreased hydrochloric acid levels

An older adult with severe rheumatoid arthritis in the upper extremities is malnourished. What does the nurse suspect as the cause of this client's malnutrition? A decrease in the client's appetite Decreasing ability to manipulate eating utensils Inadequate income to purchase sufficient food Metabolic requirements that are increased owing to immobility

Decreasing ability to manipulate eating utensils

The nurse is reviewing the medication history of a client diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase (ChE) inhibitor. The nurse contacts the primary health care provider (PHCP) if the client is taking which medication? Acetaminophen (Tylenol) Diazepam (Valium) Furosemide (Lasix) Ibuprofen (Motrin)

Diazepam (Valium)

The nurse is monitoring a client who is receiving an intravenous fat emulsion (IVFE) nutritional supplement. What action does the nurse take in the event that the client develops fever, increased triglycerides, and clotting problems? Discontinues the IVFE infusion and notifies the health care provider (HCP) Documents the findings and continues to monitor Slows the rate of flow of the IVFE infusion Switches to total parenteral nutrition (TPN)

Discontinues the IVFE infusion and notifies the health care provider (HCP)

A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? Drowsiness Hirsutism Hypertension Tachycardia

Drowsiness

The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the primary health care provider (PHCP) will request which medication to aid in the diagnosis of MG? Atropine Edrophonium chloride (Tensilon) Methylprednisolone (Solu-Medrol) Ropinirole (Requip)

Edrophonium chloride (Tensilon)

A client will be receiving plasmapheresis for treatment of Guillain-Barre'syndrome (GBS). Which posttreatment test will the nurse anticipate to be ordered? Electrolyte panel Electroencephalogram (EEG) Lumbar puncture Urinalysis

Electrolyte panel

The nurse admits a client with suspected Eaton-Lambert syndrome. The nurse anticipates that the primary health care provider (PHCP) will request which test to confirm the diagnosis? Doppler study Electromyography (EMG) Magnetic resonance imaging (MRI) Tensilon test

Electromyography (EMG)

A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? Administer phenytoin (Dilantin). Draw the client's blood. Establish an airway. Start an intravenous (IV) line.

Establish an airway.

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? Assesses the abdomen in the following sequence: inspection, palpation, percussion, auscultation Examines the RUQ of the abdomen last following all other assessment techniques. Have the client lie in a supine position with legs straight and arms at the sides Gently palpates any bulging mass and documents findings.

Examines the RUQ of the abdomen last following all other assessment techniques.

A client had a routine sigmoidoscopy with a tissue biopsy. What postprocedure complication would the nurse report to the health care provider? Gas and flatulence Excessive bleeding Nausea and vomiting Severe rectal pain

Excessive bleeding

A client on the neurosurgical floor who had a lumbar laminectomy is confused, agitated, and complaining of difficulty breathing. The client is normally alert and oriented. The nurse notices a pinpoint rash over the client's chest. What condition is the nurse concerned has occurred? Autonomic dysreflexia CSF leak Fat embolism syndrome Paralytic ileus

Fat embolism syndrome

A client receiving total parenteral nutrition (TPN) exhibits symptoms of congestive heart failure (CHF) and pulmonary edema. Which complication of TPN is the client most likely experiencing? Calcium imbalance Fluid volume deficit Fluid volume overload Potassium imbalance

Fluid volume overload

Which is the most effective way for a college student to minimize the risk for bacterial meningitis? Avoid large crowds. Get the meningococcal vaccine. Take a high dose vitamin C daily. Take prophylactic antibiotics.

Get the meningococcal vaccine.

The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment findings are normal?

Glasgow Coma Score (GCS) 15 Minimal response to stimulation Normal rapid neurologic assessment findings include a GCS (Glasgow Coma Score) of 15 and pupil constriction to light. The GCS range is between 3 and 15. Pupil constriction is a function of cranial nerve III. The pupils would be equal in size and round and regular in shape and would react to light and accommodation (PERRLA).Decerebrate or decorticate posturing is not normal, as well as pinpoint or dilated and nonreactive pupils. Both of findings are a late sign of neurologic deterioration. In addition, minimal response to stimulation and increased lethargy are not normal findings.

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? Apple juice Grape juice Grapefruit juice Prune juice

Grapefruit juice

The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving intravenous immunoglobulin (IVIG). Which assessment finding warrants immediate evaluation? Chills Generalized malaise Headache with stiff neck Temperature of 99° F (37° C)

Headache with stiff neck

The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Select all that apply. Alopecia Headaches Dizziness Diplopia Increased blood glucose

Headaches dizziness diplopia Adverse effects the nurse must monitor for in a client taking carbamazepine for partial seizures after encephalitis include: headaches, dizziness, and diplopia. Carbamazepine affects the central nervous system, although it's mechanism of action is unclear.Carbamazepine does not cause alopecia and does not increase blood glucose. Divalproex (Depakote) and valproic acid (Depakene) may cause alopecia.

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? Check for fecal impaction. Help the client sit up. Insert a straight catheter. Loosen the client's clothing.

Help the client sit up.

A client had a parathyroidectomy 8 hours ago. Which finding requires immediate attention? Edema at the surgical site Hoarseness Pain on moving the head Sore throat

Hoarseness

A client with newly diagnosed hypothyroidism tells the nurse, "I just want to feel better now. Why can't I just get a standard dose of medication instead of all this dosage adjustment?" The nurse explains that starting levothyroxine sodium (Synthroid) at a high dose may cause which of these problems? Bradycardia and decreased level of consciousness Decreased respiratory rate and hypoxemia Hypotension and shock Hypertension and heart failure

Hypertension and heart failure

A client has returned to the unit after a thymectomy and is extubated. The client begins to report chest pain. What does the nurse do next? Calls the Rapid Response Team for immediate intubation Gives sublingual nitroglycerin (Nitrostat) Increases the intravenous (IV) rate Informs the surgeon immediately

Informs the surgeon immediately

The nurse practitioner is performing an abdominal assessment on a newly admitted client. In which order should the nurse proceed with assessment technique? Auscultation, percussion, palpation, inspection Inspection, auscultation, percussion, palpation Palpation, percussion, inspection, auscultation Percussion, auscultation, palpation, inspection

Inspection, auscultation, percussion, palpation

The nurse is assessing a client who has come to the emergency department with acute abdominal pain. The client is very thin and the nurse observes visible peristaltic movements when inspecting the abdomen. What does the nurse suspect? Acute diarrhea Aortic aneurysm Intestinal obstruction Pancreatitis

Intestinal obstruction

A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. Bite block at the bedside Intravenous access (IV) Continuous sedation Suction equipment at the bedside Siderails raised

Intravenous access (IV) suction at bedside side rails raised Seizure precautions the nurse institutes for an admitted client with new-onset status epilepticus include IV access, suctioning equipment at the bedside and raised siderails. IV access is needed to administer medications. Suctioning equipment must be available to suction secretions and facilitate an open airway during a seizure. Raised, padded siderails may be used to protect the client from falling out of bed during a seizure.Bite blocks or padded tongue blades would not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

Which substance, produced in the stomach, facilitates the absorption of vitamin B12? Glucagon Hydrochloric acid Intrinsic factor Pepsinogen

Intrinsic factor

A client with Parkinson disease (PD) is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective? Involving the client and his wife in developing a plan of care Setting up visitations by a home health nurse Telling his wife what the client needs Writing up a detailed plan of care according to standards

Involving the client and his wife in developing a plan of care

An obese client has been taking orlistat (Xenical) 60 mg orally three times a day for 4 weeks, but has only lost 10 pounds (4.5 kg). The health care provider doubles the dosage and recommends behavioral changes. What behavioral changes does the nurse include in the teaching plan? Select all that apply. Cognitive restructuring to learn negative coping statements Keeping a daily food diary Identifying emotional and situational factors that stimulate eating Increasing exercise Seeking behaviors in others that one can model

Keeping a daily food diary Identifying emotional and situational factors that stimulate eating Increasing exercise

A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? Getting the client up in a chair Keeping the client in the Trendelenburg position Lifting the client in unison with other health care personnel Log rolling the client

Log rolling the client

A client is placed on orlistat (Xenical) as part of a treatment regimen for morbid obesity. What side effects does the nurse tell the client to expect from using this drug? Dry mouth, constipation, and insomnia Insomnia, dry mouth, and blurred vision Loose stools, abdominal cramps, and nausea Palpitations, constipation, and restlessness

Loose stools, abdominal cramps, and nausea

An underweight client is receiving nutritional supplements to restore nutritional status. What does the nurse do to assess the effectiveness of the supplements for the client? Keeps an accurate and precise food and fluid intake record daily Makes certain the client is weighed daily at the same time Monitors vital signs every 4 hours and as needed Assesses the client's skin for evidence of breakdown weekly

Makes certain the client is weighed daily at the same time

An older client with an elevated serum calcium level is receiving IV furosemide (Lasix) and an infusion of normal saline at 150 mL/hr. Which nursing action can the RN delegate to unlicensed assistive personnel (UAP)? Ask the client about any numbness or tingling. Check for bone deformities in the client's back. Measure the client's intake and output hourly. Monitor the client for shortness of breath.

Measure the client's intake and output hourly.

Which nursing care activity for a malnourished client does the nurse safely delegate to unlicensed assistive personnel (UAP)? Completing the Mini Nutritional Assessment Determining body mass index (BMI) Estimating body fat using skinfold measurements Measuring current height and weight

Measuring current height and weight

The nurse manager in a long-term care facility plans nutritional assessments of all residents. Which nutritional assessment activity does the nurse delegate to unlicensed assistive personnel (UAP) at the facility? Assessing residents' abilities to swallow Determining residents' functional status Measuring the daily food and fluid intake of residents Screening a portion of the residents with the Mini Nutritional Assessment

Measuring the daily food and fluid intake of residents

The nurse has just received change-of-shift report about a group of clients on the neurosurgical unit. Which client does the nurse attend to first?

Middle-aged adult client who had a cerebral aneurysm clipping and is becoming increasingly confused After a change-of-shift report, the neurosurgical nurse would first attend to the middle-aged client who had a clipping of a cerebral aneurysm and is now becoming increasingly confused. A change in level of consciousness is an early indication that central neurologic function has declined. The primary care provider must be notified immediately.The other clients are not the nurse's first priority. The young adult who is post-MVC does need to be assessed, but the client's behavior does not indicate a decline in neurologic function. The postoperative left craniotomy client and the older adult also need to be assessed, but these clients' neurologic assessment indicates better function.

The nurse notes that the client on a medical surgical unit who is being treated for hyperparathyroidism has a very high urine output. Of these actions, what will the nurse do next? Call the primary health care provider. Monitor intake and output. Perform a cardiac assessment. Slow the rate of IV fluids.

Monitor intake and output

Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy? Assess the wound dressing for bleeding. Administer morphine sulfate for pain. Monitor oxygen saturation using pulse oximetry. Support the head and neck with pillows.

Monitor oxygen saturation using pulse oximetry.

A client has Parkinson's disease (PD). Which nursing intervention best protects the client from injury? Discouraging the client from activity Encouraging the client to watch the feet when walking Monitoring the client's sleep patterns Suggesting that the client obtain assistance in performing activities of daily living (ADLs)

Monitoring the client's sleep patterns

A client arrives in the emergency department with new-onset ptosis, diplopia, and dysphagia. The nurse anticipates that the client will be tested for which neurologic disease? Bell's palsy Guillain-Barré syndrome (GBS) Myasthenia gravis (MG) Trigeminal neuralgia

Myasthenia gravis (MG)

A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? Hospital library Internet National Spinal Cord Injury Association Provider's office

National Spinal Cord Injury Association

The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the primary health care provider will prescribe which medication? Dopamine hydrochloride (Inotropin) Methylprednisolone (Solu-Medrol) Nifedipine (Procardia) Ziconotide (Prialt)

Nifedipine (Procardia)

The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct? Auscultate the abdomen to determine the presence of bowel sounds. Notify the provider about this finding immediately. Palpate the client's abdomen to determine the outlines of the mass. Question the client about recent stool habits.

Notify the provider about this finding immediately.

A young adult man says that he cannot stay on a diet because of trouble finding one that will incorporate his food preferences. How does the nurse most effectively plan nutritional care for this client? Calculates his body mass index (BMI) Records a 24-hour diary of his physical activities Obtains a 24-hour recall (diary) of his food intake Measures his accurate height and weight measurements

Obtains a 24-hour recall (diary) of his food intake

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? Indication of allergies Level of consciousness Loss of sensation Patent airway

Patent airway

Which information is most important for the nurse to communicate to the primary care provider (PCP) about a client who is scheduled for CT angiography?

Poor skin turgor and dry mucous membranes The most important information for the nurse to communicate to the PCP about a client scheduled for a CT angiography is the client with poor skin turgor and dry mucous membranes. This assessment indicates dehydration which places the client at risk for contrast induced nephropathy.Allergy to penicillin, history of bacterial meningitis, and withheld metformin will need to be reported as part of the client hand-off to Radiology (SAFETY).

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? Auscultating bowel sounds every 2 hours Beginning a bladder retraining program Monitoring nutritional status Positioning the client to maximize ventilation potential

Positioning the client to maximize ventilation potential

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? Documents the length and time of the seizure. Forces a tongue blade in the mouth. Positions the client on the side. Restrains the client.

Positions the client on the side.

An older malnourished client who is taking digoxin (Lanoxin), ranitidine (Zantac), and potassium chloride elixir (Kay Ciel) develops a severe case of diarrhea. What does the nurse suspect is a possible cause? Digoxin (Lanoxin) Gastritis Potassium chloride (Kay Ciel) Ranitidine (Zantac)

Potassium chloride (Kay Ciel)

A client with myasthenia gravis is admitted with generalized fatigue, a weak voice, and dysphagia. Which client problem has the highest priority? Inability to tolerate everyday activities related to severe fatigue Inability to communicate verbally related to vocal weakness Inability to care for self-related to muscle weakness Potential for aspiration related to difficulty with swallowing

Potential for aspiration related to difficulty with swallowing

A client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? Potential for injury related to chronic confusion and physical deficits Risk for reduced mobility related to progression of disability Potential for skin breakdown related to immobility and/or impaired nutritional status Lack of social contact related to personality and behavior changes

Potential for injury related to chronic confusion and physical deficits

After a colonoscopy, a client reports severe abdominal pain. The nurse obtains these data: temperature 100.2°F (37.9°C), pulse 122 beats/min, blood pressure 100/45 mm Hg, respirations 44 breaths/min, and O2 saturation 89%. Which request from the health care provider does the nurse implement first? Give cefazolin (Ancef) 500 mg IV. Infuse normal saline at 200 mL/hr. Give morphine sulfate 2 mg IV. Provide oxygen at 6 L/min per nasal cannula.

Provide oxygen at 6 L/min per nasal cannula.

An older adult client needs additional dietary protein, but refuses to drink the prescribed liquid protein supplements. Which nursing intervention is most effective in increasing the client's protein intake? Administering the liquid supplement with routine medications Giving a glucose polymer modular supplement Keeping a food and fluid intake diary for at least 3 days Providing protein modular supplements in the form of puddings

Providing protein modular supplements in the form of puddings

A client has undergone bariatric surgery. Which nursing intervention is the highest priority in preventing dehydration in this client? Ambulating the client as quickly as possible after surgery Applying an abdominal binder daily when the client is out of bed Observing for tachycardia, nausea, diarrhea, and abdominal cramping Providing six small feedings daily and offering fluids frequently

Providing six small feedings daily and offering fluids frequently

A client at the medical clinic is being evaluated for hypothyroidism. For which of these symptoms consistent with hypothyroidism does the nurse assess? Select all that apply. Pulse rate below 60 beats per minute Agitation and inability to sleep Increasing thermostat settings in the home Increase in appetite over the last year Bizarre or manic behavior

Pulse rate below 60 beats per minute Increasing thermostat settings in the home

A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's abdomen? (left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ))? LLQ, RLQ, LUQ, RUQ LUQ, LLQ, RUQ, RLQ RLQ, LLQ, RUQ, LUQ RUQ, LUQ, RLQ, LLQ

RUQ, LUQ, RLQ, LLQ

A client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention does the nurse perform first? Calls the Rapid Response Team (RRT) to intubate Instructs the client on how to cough effectively Raises the head of the bed to 45 degrees Suctions the client

Raises the head of the bed to 45 degrees

A client who is admitted to the intensive care unit with hyperthyroidism is fidgeting with the bedcovers and talking extremely fast. What will the nurse do next? Call the primary health care provider. Reduce any stimulation to the client. Keep the client's door open to visualize the client's actions. Tell the client to slow down.

Reduce any stimulation to the client.

An obese client with a body mass index of 30 and hypertension has been taking prescription orlistat for 4 weeks and reports loose stools, abdominal cramps, and nausea. What does the nurse recommend for this client? Asking the provider to change the medication to phendimetrazine (Bontril). Changing to the lower dose, over-the-counter form of orlistat to reduce these effects. Increasing the daily activity level to improve overall metabolism. Reducing nutritional fat intake to less than 30% of the client's daily food intake.

Reducing nutritional fat intake to less than 30% of the client's daily food intake.

A client who is receiving total enteral nutrition exhibits acute confusion and shallow breathing and says, "I feel weak." As the client begins to have a generalized seizure, how does the nurse interpret this client's signs and symptoms? The enteral tube is dislodged. Abdominal distention is present. Severe hyperglycemia is present. Refeeding syndrome is occurring.

Refeeding syndrome is occurring.

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? Encouraging nutrition Frequent ambulation Regular turning and repositioning Special pressure-relief devices

Regular turning and repositioning

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority? Nutritional therapy Occupational therapy Physical therapy Respiratory therapy

Respiratory therapy

A client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? Alzheimer's Wandering Association Lost Family Members Tracking Association National Alzheimer's Group Safe Return Program

Safe Return Program

In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? Gait Mobility Sensation Strength

Sensation

A client receiving propranolol (Inderal) as a preventative for migraine headaches is experiencing side effects after taking the drug. Which side effect is of greatest concern to the nurse? Dry mouth Slow heart rate Tingling feelings Warm sensation

Slow heart rate

Which factors place a client at risk for gastrointestinal (GI) problems? Select all that apply. Eating a high-fiber diet Smoking a half-pack of cigarettes per day Socioeconomic status Some herbal preparations Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

Smoking a half-pack of cigarettes per day Socioeconomic status Some herbal preparations Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? Neck pain is at a level 7 on a 0-to-10 scale. Serosanguineous fluid oozes onto the neck dressing. The client is reporting difficulty swallowing secretions. The client has numbness and tingling bilaterally down the arms.

The client is reporting difficulty swallowing secretions.

A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? "I can go home the day of the procedure." "I can go home 48 hours after the procedure." "I'll have a drain in place after the procedure." "I'll need to wear special stockings after the procedure."

The client's chest moves very little with each respiration.

The nurse is caring for a client in the emergency department (ED) whose spinal cord was injured at the level of C7 1 hour prior to arrival. Which assessment finding requires the most rapid action? After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg. Cardiac monitor shows a sinus bradycardia at a rate of 50 beats/min. The client's chest moves very little with each respiration. The client demonstrates flaccid paralysis below the level of injury.

The client's chest moves very little with each respiration.

Which statement correctly illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)? The client's respiratory status and muscle function are affected by both diseases. Both diseases are autoimmune diseases with ocular symptoms. Both diseases exhibit exacerbations and remissions of their signs and symptoms. Demyelination of neurons is a cause of both diseases.

The client's respiratory status and muscle function are affected by both diseases.

The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating. The nurse suspects that which cranial nerve has been affected?

Trigeminal (CN V) The nurse suspects that the trigeminal cranial nerve is affected when a client complains of difficulty chewing when eating. The trigeminal nerve affects the muscles of mastication.The abducens nerve affects eye movement via lateral rectus muscles. The facial nerve affects pain and temperature from the ear area, deep sensations in the face, and taste in the anterior two-thirds of the tongue. The trochlear nerve affects eye movement via superior oblique muscles.

A client has hyperparathyroidism. Which incident witnessed by the nurse requires the nurse's intervention? The client eating a morning meal of cereal and fruit The physical therapist walking with the client in the hallway Unlicensed assistive personnel (UAP) pulling the client up in bed by the shoulders Visitors talking with the client about going home

Unlicensed assistive personnel (UAP) pulling the client up in bed by the shoulders

The nurse obtains assessment data on a client who had bariatric surgery today. Which finding does the nurse report to the surgeon immediately? Bowel sounds are not audible in all quadrants. Client's skin under the panniculus is excoriated. The client reports pain when being repositioned. Urine output total is 15 mL for the past 2 hours.

Urine output total is 15 mL for the past 2 hours.

A client who has undergone a bariatric surgical procedure is recuperating after surgery. Which nursing intervention most effectively prevents injury to the client who is being re-positioned postoperatively? Administering pain medication Making sure not to move the client's nasogastric (NG) tube Monitoring skinfold areas and keeping them clean and dry Using a weight-rated extra-wide bed for the client

Using a weight-rated extra-wide bed for the client

Which cranial nerve allows a person to feel a light breeze on the face?

V (trigeminal) Cranial nerve V (trigeminal) allows the person to feel a light breeze on the face. This nerve is responsible for sensation from the skin of the face and scalp and the mucous membranes of the mouth and nose.Cranial nerve I (olfactory) is responsible for smell. Cranial nerve III (oculomotor) is responsible for eye movement. Cranial nerve VII (facial) is responsible for pain and temperature from the ear area, deep sensations from the face, and taste from the anterior two thirds of the tongue.

Based on nutritional screening findings and assessments, which client will be the preferred candidate for surgical treatment for obesity? Man with a body mass index (BMI) of 40, weight 75% above ideal body weight Man with a BMI of 41, weight 80% above ideal body weight Woman with a BMI of 38, weight 50% above ideal body weight Woman with a BMI of 42, weight 100% above ideal body weight

Woman with a BMI of 42, weight 100% above ideal body weight

An 87-year-old resident from an extended care facility has not been eating for several days and is admitted to the hospital with a diagnosis of malnutrition. She has an enteral feeding tube placed in her left nostril. Her medications include digoxin (Lanoxin), ranitidine (Zantac), and potassium chloride elixir (Kay Ciel). The nurse checks the gastric pH of the feeding tube and obtains a value of 6.0, which may indicate that the feeding tube is in the client's lungs. Is there another possible explanation for the nurse to consider? No; the feeding tube must be removed. No; the potassium effect will prevent the pH from reaching 6.0. Yes; the client is taking Zantac. Yes; the pH paper has expired and is giving a false reading.

Yes; the client is taking Zantac.

The nurse has received report on a group of clients. Which client requires the nurse's attention first? Adult who is lethargic after a generalized tonic-clonic seizure Young adult who has experienced four tonic-clonic seizures within the past 30 minutes Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

Young adult who has experienced four tonic-clonic seizures within the past 30 minutes

Which client diagnosed with neurologic injury is typically at highest risk for depression?

Young man with a spinal cord injury A young man with a spinal cord injury is at highest risk for depression. Although each individual responds differently, young adults who experience a spinal cord injury and loss of independent movement are more likely to experience depression.Keeping in mind people's differences in personal experiences, the client with a mild stroke without long-term deficits, the client who had a seizure or the young woman who sustained a minor head injury are generally at a lower risk of depression.

A client has Guillain-Barré syndrome. Which interdisciplinary health care team members does the nurse plan to collaborate with to help prevent pressure ulcers related to immobility in this client? Select all that apply. Certified hospital chaplain Family members Dietitian Occupational therapist (OT), Social worker

family members dietitian Occupational therapist (OT), Social worker