NRSG 2510 Exam 2: Practice Questions
A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"
"Do you feel afraid that people are trying to hurt you?" It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.
The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? 1. "Have you had any headaches in the past few days?" 2. "Have you recently been having difficulty with seeing at nighttime?" 3. "Have you had any sudden episodes of passing out in the past few days?" 4. "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"
"Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?" Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on 1 side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.
A client diagnosed with paranoid schizophrenia refuses food, stating the voices are saying the food is contaminated and deadly. Which response should the nurse provide to this client statement? "You are safe here in the hospital; nothing bad will happen to you." "The voices are wrong about the hospital food. It is not contaminated." "I understand that the voices are very real to you, but I do not hear them." "Other people are eating the food, and nothing is happening to them."
"I understand that the voices are very real to you, but I do not hear them." This reply acknowledges the client's reality but offers the nurse's perception that he or she is not experiencing the same thing. This is the only option that provides such support
A client diagnosed with schizophrenia states to the nurse, "My, oh my. My mother is brother. Anytime now it can happen to my mother." Your best response would be: "You are having problems with your speech. You need to try harder to be clear." "You are confused. I will take you to your room to rest a while." "I will get you a prn medication for agitation." "I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?"
"I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?" The guidelines that are useful in communicating with a patient with disorganized or bizarre speech are to place the difficulty in understanding on yourself, not the patient, and look for themes that may be helpful in interpreting what the patient wants to say. Telling the patient he needs to try harder to be clearer is unrealistic since the patient would be unable do this. The other options are not useful in communicating with this patient and attempting to find common theme
When a client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me," an appropriate response for the nurse would be: "You are safe here. This is a locked unit, and no one can get in." "I do not believe I understand the word volmers. Tell me more about them." "Why do you think someone or something is going to harm you?" "It must be frightening to think something is going to harm you."
"It must be frightening to think something is going to harm you." This response focuses on the client's feelings and neither directly supports the delusion nor denies the client's experience. Option A gives global reassurance. Option B encourages elaboration about the delusion. Option C asks for information that the client will likely be unable to answer
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."
"We need to remind him to turn his head to scan the lost visual field." Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? 1. "My medications will help my anxious feelings." 2. "I'll go to support group and talk about what I am feeling." 3. "I need to get enough sleep and eat well to help prevent feeling anxious." 4. "When I have command hallucinations, I'll call a friend and ask him what I should do."
"When I have command hallucinations, I'll call a friend and ask him what I should do." The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, should be contacted to discuss whether the client has intentions to hurt himself or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness, but are not specific interventions for hallucinations, if they occur.
A client diagnosed with schizophrenia says to the nurse, "Will you protect me from the Grand Duchess?" and points to an older client who is sitting reading a book. Which statement is the therapeutic response by the nurse? 1. "Where is she? I'll talk to her." 2. "I can see no Grand Duchess. You will need to trust me on that." 3. "You will be safe here. Your thinking will be clearer after your medication starts to work." 4. "The Grand Duchess, huh? Well, I'm the Queen, and I will order her to stay away from you."
"You will be safe here. Your thinking will be clearer after your medication starts to work." The schizophrenic client is making a paranoid statement. It is important that the nurse provide the client with a supportive and protective intervention. The correct option is the only one that reflects a therapeutic technique, presents reality, and addresses safety. To ask, "Where is she? I'll talk to her" is not therapeutic because the nurse feeds into the client's psychosis by asking where the fantasy client is. To state that you do not see the Grand Duchess and that the client needs to trust you begins by presenting reality, but it does not demonstrate any real support for the client's concern with safety. To say that you are the Queen and will order the Grand Duchess to stay away is sarcastic and belittling to the client.
Currently what is understood to be the causation of schizophrenia? 1) A combination of inherited and non-genetic factors 2) Deficient amounts of the neurotransmitter dopamine 3) Excessive amounts of the neurotransmitter serotonin 4) Stress related and ineffective stress management skills
A combination of inherited and nongenetic factors Causation is a complicated matter. Schizophrenia most likely occurs as a result of a combination of inherited genetic factors and extreme nongenetic factors (e.g., viral infection, birth injuries, nutritional factors) that can affect the genes governing the brain or directly injure the brain
Which of the following would be assessed as a negative symptom of schizophrenia? 1) Anhedonia 2) Hostility 3) Agitation 4) Hallucinations
Anhedonia Negative symptoms refer to deficits that characterize schizophrenia. They include the crippling symptoms of affective blunting (lack of facial expression), anergia (lack of energy), anhedonia (inability to experience happiness), avolition (lack of motivation), poverty of content of speech, poverty of speech, and thought blocking
A client, who has been prescribed clozapine 6 weeks ago, reports flulike symptoms including a fever and a very sore throat, the nurse should initiate which nursing intervention? Suggest that the client take something for the fever and get extra rest. Advise the physician that the client should be admitted to the hospital. Arrange for the client to have blood drawn for a white blood cell count. Consider recommending a change of antipsychotic medication.
Arrange for the client to have blood drawn for a white blood cell count. Antipsychotic medications may cause agranulocytosis, the first manifestation of which may be a sore throat and flulike symptoms
The nurse creating a plan of care for the client demonstrating paranoia should include which interventions in the plan of care? Select all that apply. 1. Ask permission before touching the client. 2. Provide a warm, social approach to the client. 3. Eliminate all unnecessary physical contact with the client. 4. Defuse any anger or verbal attacks with a nondefensive stance. 5. Use simple and clear language when communicating with the client.
Ask permission before touching the client. Eliminate all unnecessary physical contact with the client. Defuse any anger or verbal attacks with a nondefensive stance. Use simple and clear language when communicating with the client. When caring for a client with paranoia, the nurse should ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client unless necessary and with the client's permission. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language should be used in speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The nurse should avoid a warm approach because warmth can be frightening to a person who needs emotional distance.
The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech? 1. Intact 2. Rambling 3. Characterized by literal paraphasia 4. Associated with poor comprehension
Associated with poor comprehension Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words spoken by another, and speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke's aphasia may exhibit a rambling type of speech.
A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? 1. Return of spinal shock 2. Malignant hypertension 3. Impending brain attack (stroke) 4. Autonomic dysreflexia (hyperreflexia)
Autonomic dysreflexia (hyperreflexia) Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.
The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? 1. Blood pressure 2. Motor response 3. Pupillary response 4. Level of consciousness
Blood pressure Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. The remaining options are unrelated to monitoring for Cushing's reflex
A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1. Nausea 2. Irritability 3. Headache 4. Bradycardia
Bradycardia Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased ICP. In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.
The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1. Confusion 2. Bradycardia 3. Sluggish pupils 4. A widened pulse pressure
Confusion Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the late stages.
The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 1. Insert nasal packing. 2. Document the findings. 3. Contact the health care provider (HCP). 4. Monitor the client's blood pressure and check for signs of increased intracranial pressure.
Contact the health care provider (HCP). Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP, because this finding requires immediate intervention. The remaining options are inappropriate nursing actions in this situation.
Schizophrenia is best characterized as presenting which personality trait? 1) Split 2) Multiple 3) Ambivalent 4) Deteriorating
Deteriorating The course of schizophrenia is marked by recurrent acute exacerbations. With each relapse of psychosis, an increase in residual dysfunction and deterioration occurs.
The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation? 1. During the entire family visit, the client presented with an expressionless, blank look. 2. The client demonstrated minimal response to the news that his discharge had been postponed. 3. The client grimaced during the entire therapy session that focused on finding one's personal joy. 4. During grief therapy, the client was observed laughing while another client described the death of a parent.
During the entire family visit, the client presented with an expressionless, blank look. A flat affect is manifested as an immobile facial expression or blank look. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation.
The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1. Elevate the head of the bed. 2. Examine the rectum digitally. 3. Assess the client's blood pressure. 4. Place the client in the prone position.
Elevate the head of the bed. Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position; lying flat will increase the client's blood pressure.
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning
Exhaling during repositioning Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder
Flaccid paralysis Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose.
Fluid separates into concentric rings and tests positive for glucose. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.
A client diagnosed with disorganized schizophrenia would have greatest difficulty with the nursing intervention? Interacting with a neutral attitude Using concrete language Giving multistep directions Providing nutritional supplements
Giving multistep directions The thought processes of the client with disorganized schizophrenia are severely disordered, and severe perceptual problems are present, making it extremely difficult for the client to understand what others are saying. All communication should be simple and concrete and may need to be repeated several times. Ineffective organizational skills would not be a primary factor considering the other options
The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1. Head midline 2. Neck in neutral position 3. Head of bed elevated 30 to 45 degrees 4. Head turned to the side when flat in bed 5. Neck and jaw flexed forward when opening the mouth
Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.
Nico, a 22-year-old patient, is diagnosed with schizophrenia. Which of the following symptoms would alert a provider to a possible diagnosis of schizophrenia in a 22-year-old male client? Excessive sleeping with disturbing dreams Hearing voices telling him to hurt his roommate Withdrawal from college because of failing grades Chaotic and dysfunctional relationships with his family and peers
Hearing voices telling him to hurt his roommate People diagnosed with schizophrenia all have at least one psychotic symptom such as hallucinations, delusional thinking, or disorganized speech. The other options do not describe schizophrenia but could be caused by a number of problems.
The nurse is planning to instruct a mental health client and the family about the importance of medication compliance. The nurse should plan for which interventions that are associated with increased compliance? Select all that apply. 1. Including the family in the medication planning process 2. Arranging medication administration to occur once per day 3. Working with the psychiatrist to find the right medication at the right dose 4. Providing the client with the injectable, long-acting form of the medication if available 5. Working with the psychiatrist to find the medication that provides the least side effects for the client
Including the family in the medication planning process Working with the psychiatrist to find the right medication at the right dose Providing the client with the injectable, long-acting form of the medication if available Working with the psychiatrist to find the medication that provides the least side effects for the client Including the family in the medication planning process; providing clients with the injectable, long-acting form of the medication; and finding the right medication at the right dose that provides the fewest side effects for the client are measures that will promote compliance. Not all medications can be given on a once-per-day dosing regimen because of their short half-life.
The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome? 1. Encourage communication. 2. Provide a consistent daily routine. 3. Promote adequate bowel elimination. 4. Increase the client's awareness of the affected side.
Increase the client's awareness of the affected side. In anosognosia, the client exhibits neglect of the affected side of the body. The nurse will plan care activities that remind the client to perform actions that require looking at the affected arm or leg, as well as activities that will increase the client's awareness of the affected side. The remaining options are not associated with this deficit.
The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.
The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? 1. Had a very mild stroke 2. Most likely suffered a transient ischemic attack 3. May have difficulty with language abilities only 4. Is likely to have perceptual and spatial disabilities
Is likely to have perceptual and spatial disabilities The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week
Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Turning and repositioning the client at least every 2 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1. Updating the home safety sheet 2. Leaving the client in an unchilled area of the room 3. Noting a bowel movement on the client progress note 4. Recording the amount of urine obtained with catheterization
Leaving the client in an unchilled area of the room The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. 1. Loosening restrictive clothing 2. Restraining the client's limbs 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward 5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist
Loosening restrictive clothing Removing the pillow and raising padded side rails Positioning the client to the side, if possible, with the head flexed forward Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.
The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the health care provider's (HCP's) prescriptions and should contact the HCP to question which prescription? 1. Obtain daily weight. 2. Provide clear liquid intake. 3. Nasotracheal suction as needed. 4. Maintain a patent intravenous line.
Nasotracheal suction as needed. A basilar skull fracture is a type of head injury. Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture: Because of the nature of the injury, there is a possibility that the catheter will enter the brain through the fracture, creating a high risk of secondary infection. Fluid balance is monitored closely by daily weight determination, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on NPO (nothing by mouth) status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications, if necessary.
The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent
Padding the side rails of the bed Placing an airway at the bedside Placing oxygen and suction equipment at the bedside Flushing the intravenous catheter to ensure that the site is patent Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.
The nurse is planning long-term goals for a 17-year-old male client recently diagnosed with schizophrenia. Which statement should serve as the basis for the goal-setting process? If treated quickly following diagnosis, schizophrenia can be cured. Schizophrenia can be managed by receiving treatment only at the time of acute exacerbations. Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability. If patients with schizophrenia stay on their drug regimen, they usually lead fully productive lives with no further symptoms.
Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability. Unfortunately, in most cases, schizophrenia does not respond fully to available treatments; it leaves residual symptoms and causes varying degrees of dysfunction or disability. The other options are all untrue of schizophrenia
The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. 1. Postictal status 2. Duration of the seizure 3. Changes in pupil size or eye deviation 4. Seizure progression and type of movements 5. What the client ate in the 2 hours preceding seizure activity
Postictal status Duration of the seizure Changes in pupil size or eye deviation Seizure progression and type of movements Typically seizure assessment includes the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status. Determining what the client ate 2 hours prior to the seizure is not a component of seizure assessment.
The most common course of schizophrenia is an initial episode followed by what course of events? 1) Recurrent acute exacerbations and deterioration 2) Recurrent acute exacerbations 3) Continuous deterioration 4) Complete recovery
Recurrent acute exacerbations and deterioration Schizophrenia is usually a disorder marked by an initial episode followed by recurrent acute exacerbations. With each relapse of psychosis, an increase in residual dysfunction and deterioration occurs
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities
Rigid extension and pronation of the arms and legs Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.
A teenaged client is being discharged from the psychiatric unit with a prescription for risperidone. The nurse providing medication teaching to the client's mother should provide which response when asked about the risk her son faces for extrapyramidal side effects (EPSs)? All antipsychotic medications have an equal chance of producing EPSs. Newer antipsychotic medications have a higher risk for EPSs. Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics. Advise the mother to ask the provider to change the medication to clozapine instead of risperidone.
Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics. Risperidone is a newer, atypical antipsychotic. All newer antipsychotic medications have a lower incidence of EPSs than older, traditional antipsychotics. The other responses are untrue. There is no reason to advise a medication change at this time
The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone so as to minimize external stimuli. 3. Sit beside the client in silence with occasional open-ended questions. 4. Take the client into the dayroom with other clients so that they can help watch them.
Sit beside the client in silence with occasional open-ended questions. Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. While overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients.
A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result? 1. Hypotension 2. Tachycardia 3. Slurred speech 4. No abnormal finding
Slurred speech The therapeutic phenytoin level is 10 to 20 mcg/mL (40 to 79 mcmol/L). At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL (120 mcmol/L), ataxia and slurred speech occur.
A client has reached the stable plateau phase of schizophrenia. What is the appropriate clinical planning focus for this client? Safety and crisis intervention Acute symptom stabilization Stress and vulnerability assessment Social, vocational, and self-care skills
Social, vocational, and self-care skills During the stable plateau phase of schizophrenia, planning is geared toward client and family education and skills training that will help maintain the optimal functioning of schizophrenic individuals in the community. All the other options should have been handled previously
The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? 1. Body stiffening 2. Spasms of the entire body 3. Sudden loss of consciousness 4. Brief flexion of the extremities
Spasms of the entire body The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Body stiffening, sudden loss of consciousness, and brief flexion of the extremities are associated with the tonic phase of a seizure.
The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen
Suctioning equipment and oxygen A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside, but would be available in the treatment room or nearby on the nursing unit.
Tara and Aaron are twins who are both diagnosed with schizophrenia. Aaron was diagnosed at 23 years old and Tara at 31 years old. Based on your knowledge of early and late onset of schizophrenia, which of the following is true? Tara and Aaron have the same expectation of a poor long-term prognosis. Tara will experience more positive signs of schizophrenia such as hallucinations. Aaron will be more likely to hold a job and live a productive life. Tara has a better chance for positive outcomes because of later onset.
Tara has a better chance for positive outcomes because of later onset. Female patients diagnosed with schizophrenia between the ages of 25 and 35 years have better outcomes than do their male counterparts diagnosed earlier. These two patients do not have the same expectation of a poor prognosis. There is no evidence suggesting that Tara will have more positive signs of schizophrenia. It is actually more unlikely that Aaron will be able to live a productive life because of his earlier onset, which has a poorer prognosis.
Which side effect of antipsychotic medication is generally nonreversible? 1) Anticholinergic effects 2) Pseudoparkinsonism 3) Dystonic reaction 4) Tardive dyskinesia
Tardive dyskinesia Tardive dyskinesia is not always reversible with discontinuation of the medication and has no proven cure. The other side effects often appear early in therapy and can be minimized with treatment
Which nursing intervention is designed to help a schizophrenic client minimize the occurrence of a relapse? Schedule the client to attend group therapy that includes those who have relapsed. Teach the client and family about behaviors associated with relapse. Remind the client of the need to return for periodic blood draws to minimize the risk for Relapse. Help the client and family adapt to the stigma of chronic mental illness and periodic relapses.
Teach the client and family about behaviors associated with relapse. By knowing what behaviors signal impending relapse, interventions can be quickly invoked when the behaviors occur. The earlier the intervention, the greater the likelihood that a recurrence can be averted. None of the other options are effective interventions when considering relapse prevention
The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? 1. Sudden loss of consciousness occurred. 2. Signs and symptoms occurred suddenly. 3. The client experienced paresthesias a few days before admission to the hospital. 4. The client complained of a severe headache, which was followed by sudden onset of paralysis.
The client experienced paresthesias a few days before admission to the hospital. Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on 1 side of the body. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke (brain attack) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.
The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect? 1. When told that a beloved pet has died, the client responds, "OK." 2. The client giggled while describing being physically abused as a child. 3. The client's facial expressions are unchanged during the entire admission process. 4. When staff members attempt to engage the client in conversation, the client only mumbles.
The client giggled while describing being physically abused as a child. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.
The client is aphasic. The client has weakness on the right side of the body. The client has weakness on the right side of the face and tongue. Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.
The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? 1. The client will be easily fatigued. 2. The client will have difficulty speaking. 3. The client will have difficulty swallowing. 4. The client will exhibit neglect of the affected side.
The client will exhibit neglect of the affected side. In anosognosia, the client neglects the affected side of the body. The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else. The remaining options are not associated with anosognosia.
Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? 1. The client's noncompliance with medication therapy 2. The community's opposition to outpatient mental health clinics 3. The associated increased risk that the client may become homeless 4. The family's negative reaction to transferring the client to community-based care
The client's noncompliance with medication therapy Clients often forget to take their medications as scheduled, and this is the most prominent problem since medication therapy is vital to the function of clients with such a diagnosis. While the situations described in the remaining options may occur, these problems are not as impacting on the client's prognosis and can be addressed and often controlled.
The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? 1. The intracranial pressure reading is normal. 2. The intracranial pressure reading is elevated. 3. The intracranial pressure reading is borderline. 4. An intracranial pressure reading of 8 mm Hg is low.
The intracranial pressure reading is normal. The normal intracranial pressure is 5 to 15 mm Hg. A pressure of 8 mm Hg is within normal range.
The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.
Time the seizure. Stay with the child. Move furniture away from the child. A seizure is a disorder that occurs as a result of excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side prevents aspiration because saliva drains out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.
A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1. Using open-ended questions and silence 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition
Using open-ended questions and silence Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.
A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1. Platelet count 2. Cholesterol level 3. Blood urea nitrogen 4. White blood cell count
White blood cell count Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to this medication.
A client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me." The term "volmers" can be assessed as 1) a neologism. 2) clang association. 3) blocking. 4) a delusion.
a neologism. A neologism is a newly coined word that has meaning only for the client. None of the other options fit this description
The purpose of the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has been diagnosed with schizophrenia is early detection of acute dystonia. tardive dyskinesia. cholestatic jaundice. pseudoparkinsonism.
tardive dyskinesia. An AIMS assessment should be performed periodically on clients who are being treated with antipsychotic medication known to cause tardive dyskinesia. This tool is not used to assess or monitor any of the other options.