Week 6 Clinical Review Questions

If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: A. Body temperature control B. Balance and equilibrium C. Visual acuity D. Thinking and reasoning

A. Body temperature control

When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: A. Light flashes and floaters in front of the eye. B. A recent driving accident while changing lanes. C. Headaches, nausea, and redness of the eyes. D. Frequent episodes of double vision.

A. Light flashes and floaters in front of the eye.

Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? A. Placing the client on the back with a small pillow under the head. B. Keeping portable suctioning equipment at the bedside. C. Opening the client's mouth with a padded tongue blade. D. Cleaning the client's mouth and teeth with a toothbrush.

A. Placing the client on the back with a small pillow under the head.

1. To encourage adequate nutritional intake for a female client with Alzheimer's disease, the nurse should: A. Stay with the client and encourage him to eat. B. Help the client fill out his menu. C. Give the client privacy during meals. D. Fill out the menu for the client.

A. Stay with the client and encourage him to eat.

The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? A. Tachycardia B. Increased salivation C. Hypotension D. Apnea

A. Tachycardia

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases. B. Pupils are 8 mm and nonreactive. C. Systolic blood pressure remains at 150 mm Hg. D. BUN and creatinine levels return to normal.

A. Urine output increases.

A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client's behavior. A. Is disoriented to person, place, and time. B. Affect is flat, with periods of emotional lability. C. Cannot recall what was eaten for breakfast today. D. Demonstrate inability to add and subtract; does not know who is the president.

B. Affect is flat, with periods of emotional lability.

A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? A. A private room down the hall from the nurses' station. B. An isolation room three doors from the nurses' station. C. A semi-private room with a 32-year-old client who has viral meningitis. D. A two-bedroom with a client who previously had bacterial meningitis.

B. An isolation room three doors from the nurses' station.

A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines which of the following results would verify the diagnosis? A. Cloudy CSF, decreased protein, and decreased glucose. B. Cloudy CSF, elevated protein, and decreased glucose. C. Clear CSF, elevated protein, and decreased glucose. D. Clear CSF, decreased pressure, and elevated protein.

B. Cloudy CSF, elevated protein, and decreased glucose.

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? A. Immobilize the neck before the client is moved onto a stretcher. B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. C. Place a cap on the client's head. D. Administer a sedative as ordered.

B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination D. Risk for injury

B. Ineffective airway clearance

A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Self-care deficit: Dressing/grooming

B. Ineffective breathing pattern

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? A. Vomiting continues. B. Intracranial pressure (ICP) is increased. C. The client needs mechanical ventilation. D. Blood is anticipated in the cerebrospinal fluid (CSF).

B. Intracranial pressure (ICP) is increased.

During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: A. Use the pointed end of the reflex hammer when striking the Achilles' tendon. B. Support the joint where the tendon is being tested. C. Tap the tendon slowly and softly. D. Hold the reflex hammer tightly.

B. Support the joint where the tendon is being tested.

A female client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? A. The client leaves the side rails down. B. The client uses a mirror to inspect the skin. C. The client repositions only after being reminded to do so. D. The client hangs the left arm over the side of the wheelchair.

B. The client uses a mirror to inspect the skin.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 mg/dl. B. A right-sided carotid bruit. C. A blood pressure of 220/120 mmHg. D. The presence of bronchogenic carcinoma.

C. A blood pressure of 220/120 mmHg.

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature

C. Blood pressure

The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? A. Cerebellar function B. Intellectual function C. Cerebral function D. Sensory function

C. Cerebral function

What is the expected outcome of thrombolytic drug therapy? A. Increased vascular permeability B. Vasoconstriction C. Dissolved emboli D. Prevention of hemorrhage

C. Dissolved emboli

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: A. Tolerate the pain. B. Decrease the perception of pain. C. Escape the source of pain. D. Divert attention from the source of pain.

C. Escape the source of pain.

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? A. No precautions are required as long as antibiotics have been started. B. Maintain enteric precautions. C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics. D. Maintain neutropenic precautions.

C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? A. Caucasian race B. Female sex C. Obesity D. Bronchial asthma

C. Obesity

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? A. Frontal B. Occipital C. Parietal D. Temporal

C. Parietal

A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? A. Giving the client full control over care decisions and restricting visitors. B. Providing positive feedback and encouraging active range of motion. C. Providing information, giving positive feedback and encouraging relaxation. D. Providing intravenously administered sedatives, reducing distractions and limiting visitors.

C. Providing information, giving positive feedback and encouraging relaxation.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? A. Bradycardia B. Large amounts of very dilute urine C. Restlessness and confusion D. Widened pulse pressure

C. Restlessness and confusion

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for A STAT computer tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consultation.

C. Schedule for A STAT computer tomography (CT) scan of the head.

You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN? A. Complete admission assessment. B. Place a padded tongue blade at the bedside. C. Set up oxygen and suction equipment. D. Pad the side rails before the patient arrives.

C. Set up oxygen and suction equipment.

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A. The assistant places a gait belt around the client's waist prior to ambulating. B. The assistant places the client on the back with the client's head to the side. C. The assistant places her hand under the client's right axilla to help him/her move up in bed. D. The assistant praises the client for attempting to perform ADL's independently.

C. The assistant places her hand under the client's right axilla to help him/her move up in bed.

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? A. To reduce intraocular pressure. B. To prevent acute tubular necrosis. C. To promote osmotic diuresis to decrease ICP. D. To draw water into the vascular system to increase blood pressure.

C. To promote osmotic diuresis to decrease ICP.

Which client would the nurse identify as being most at risk for experiencing a CVA? A. A 39-year-old pregnant female. B. A 67-year-old Caucasian male. C. An 84-year-old Japanese female. D. A 55-year-old African American male.

D. A 55-year-old African American male.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. A thrombolytic medication B. A beta-blocker medication C. An anti-hyperuricemic medication D. An oral anticoagulant medication

D. An oral anticoagulant medication

The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the physician immediately.

D. Call the physician immediately.

A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure the client to ensure client safety? A. Speak loudly to the client. B. Test the temperature of the shower water. C. Check the temperature of the food on the delivery tray. D. Provide a clear path for ambulation without obstacles.

D. Provide a clear path for ambulation without obstacles.

A male client is having tonic-clonic seizures. What should the nurse do first? A. Elevate the head of the bed. B. Restrain the client's arms and legs. C. Place a tongue blade in the client's mouth. D. Take measures to prevent injury.

D. Take measures to prevent injury.

Problems with memory and learning would relate to which of the following lobes? A. Frontal B. Occipital C. Parietal D. Temporal

D. Temporal

Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except? A. acetaminophen (Tylenol) B. dexamethasone (Decadron) C. mannitol (Osmitrol) D. phenytoin (Dilantin) E. nitroglycerin (Nitrostat)

E. nitroglycerin (Nitrostat)

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

B. Pupil size and pupillary response

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? A. Limiting conversation with the child. B. Allowing the child to play in the bathtub. C. Keeping extraneous noise to a minimum. D. Performing treatments quickly.

C. Keeping extraneous noise to a minimum.

Emergency medical technicians transport a 27-year-old ironworker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag." Which intervention by the nurse has the highest priority? A. Assessing the left leg. B. Assessing the pupils. C. Placing the client in Trendelenburg's position. D. Assessing level of consciousness.

A. Assessing the left leg.