a1

When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred? 1. C3 2. C5 3. T6 4. L1

C5

Emergency medical technicians transport a client 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? 1. Assessing the left leg 2. Assessing the pupils 3. Placing the client in Trendelenburg's position 4. Assessing level of consciousness (LOC)

assess leg

While looking out the window at trees, a client with schizophrenia remarks, "That school across the street has creatures in it that are waiting for me." Which term best describes what the creatures represent? 1. Anxiety attack 2. Projection 3. Hallucination 4. Delusion

delusion

A client with hypertension comes to the outpatient department for a routine checkup. Because hypertension is a risk factor for cerebral hemorrhage, the nurse questions the client closely about warning signs and symptoms of hemorrhage. Which complaint is a possible indicator of cerebral hemorrhage in this client? 1. Vertigo 2. Tinnitus 3. Generalized seizures 4. Nausea

tinnitus

How soon after chlorpromazine (Thorazine) administration should a nurse expect to see a client's delusional thoughts and hallucinations eliminated? 1. Several minutes 2. Several hours 3. Several days 4. Several weeks

weeks

While pacing in the hall, a client with paranoid schizophrenia runs to a nurse and asks, "Why are you poisoning me? I know you work for Central Thought Control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process? 1. "I'm a nurse. I'm not poisoning you. That would be a violation of the nursing code of ethics." 2. "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." 3. "I'm not poisoning you. And how could I possibly steal your soul?" 4. "I sense anger. Are you feeling angry today?"

2. "I'm a nurse, and you're a client in the hospital. I'm not going to harm you."

Which effects do most antipsychotic medications exert on the central nervous system (CNS)? 1. They stimulate the CNS by blocking postsynaptic dopamine, norepinephrine, and serotonin receptors. 2. They sedate the CNS by stimulating serotonin at the synaptic cleft. 3. They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine. 4. They depress the CNS by stimulating the release of acetylcholine.

3. They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine.

Which condition or characteristic is related to the cluster of symptoms associated with disorganized schizophrenia? 1. Odd beliefs 2. Flat affect 3. Waxy flexibility 4. Systematized delusions

2. Flat affect

A client asks a nurse, "How does ergotamine (Ergostat) relieve migraine headaches?" The nurse should respond that it: 1. dilates cerebral blood vessels. 2. constricts cerebral blood vessels. 3. decreases peripheral vascular resistance. 4. decreases the stimulation of baroreceptors.

2. constricts cerebral blood vessels.

A client with slight memory impairment and poor concentration is diagnosed with primary degenerative dementia of the Alzheimer's type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer's disease, the nurse should observe the client for: 1. occasional irritable outbursts. 2. impaired communication. 3. lack of spontaneity. 4. inability to perform self-care.

2. impaired communication

A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective is for hallucinating clients to: 1. take an as-needed dose of psychotropic medication whenever they hear voices. 2. practice saying, "Go away" or "Stop" when they hear voices. 3. sing loudly to drown out the voices and provide a distraction for themselves. 4. go to their room until they can't hear the voices.

2. practice saying, "Go away" or "Stop" when they hear voices.

A client who has been hospitalized with disorganized type schizophrenia for 8 years can't perform activities of daily living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of Dressing or grooming self-care deficit related to inability to function without assistance. What is an appropriate goal for this client? 1. "Client will be able to complete ADLs independently within 1 month." 2. "Client will be able to complete ADLs with only verbal encouragement within 1 month." 3. "Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month." 4. "Client will be able to complete ADLs with complete assistance within 1 month."

3. "Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month."

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? 1. Flat 2. Supine, with the head of the bed elevated 30 degrees 3. Flat, except for logrolling as needed 4. A head elevation of 90 degrees to prevent cerebral swelling

3. Flat, except for logrolling as needed

A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism? 1. Restlessness, difficulty sitting still, and pacing 2. Involuntary rolling of the eyes 3. Tremors, shuffling gait, and masklike face 4. Extremity and neck spasms, facial grimacing, and jerky movements

3. Tremors, shuffling gait, and masklike face

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? 1. Checking stools for occult blood 2. Performing range-of-motion (ROM) exercises on the left side 3. Keeping skin clean and dry 4. Elevating the head of the bed to 30 degrees

4. Elevating the head of the bed to 30 degrees

A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate? 1. Establishing an intermittent catheterization routine every 4 hours 2. Managing spasticity with range-of-motion exercises and medications 3. Establishing an ambulation program using short leg braces 4. Preventing autonomic dysreflexia by preventing bowel impaction

1. Establishing an intermittent catheterization routine every 4 hours

Which group of characteristics should a nurse expect to see in the client with schizophrenia? 1. Loose associations, grandiose delusions, and auditory hallucinations 2. Periods of hyperactivity and irritability alternating with depression 3. Delusions of jealousy and persecution, paranoia, and mistrust 4. Sadness, apathy, feelings of worthlessness, anorexia, and weight loss

1. Loose associations, grandiose delusions, and auditory hallucinations

A nurse is assigned to care for a client with anorexia nervosa. During the first 48 hours of treatment, which nursing intervention is most appropriate for this client? 1. Providing one-on-one supervision during meals and for 1 hour afterward 2. Letting the client eat with other clients to create a normal mealtime atmosphere 3. Trying to persuade the client to eat and thus restore nutritional balance 4. Giving the client as much time to eat as desired

1. Providing one-on-one supervision during meals and for 1 hour afterward

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? 1. Rising blood pressure and bradycardia 2. Hypotension and bradycardia 3. Hypotension and tachycardia 4. Hypertension and narrowing pulse pressure

1. Rising blood pressure and bradycardia

A client with paranoid schizophrenia is admitted to the psychiatric unit of a hospital. Nursing assessment should include careful observation of the client's: 1. thinking, perceiving, and decision-making skills. 2. verbal and nonverbal communication processes. 3. affect and behavior. 4. psychomotor activity.

1. thinking, perceiving, and decision-making skills

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? 1. Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. 2. Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. 3. Reassure the client that a headache is expected and will go away without treatment. 4. Notify the physician; a headache is an early sign of worsening neurologic status.

2. Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? 1. Positioning the client to prevent airway obstruction 2. Keeping the client in one position to decrease bleeding 3. Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess 4. Maintaining the client in a quiet environment

2. Keeping the client in one position to decrease bleeding

A nurse is monitoring a client who is having hallucinations. The nurse notes paranoid content in the client's speech, and he appears agitated. The client is gesturing at a figure on the television. Which nursing interventions are appropriate? Select all that apply. 1. In a firm voice, instruct the client to stop the behavior. 2. Reinforce that the client isn't in any danger. 3. Acknowledge the presence of the hallucinations. 4. Instruct other team members to ignore the client's behavior. 5. Immediately implement physical restraint procedures. 6. Use a calm voice and simple commands.

2. Reinforce that the client isn't in any danger. 3. Acknowledge the presence of the hallucinations. 6. Use a calm voice and simple commands.

When teaching the family of a client with schizophrenia, the nurse should provide which information? 1. Relapse can be prevented if the client takes his medication. 2. Support is available to help family members meet their own needs. 3. Improvement should occur if the client is provided with a stimulating environment. 4. Stressful family situations can precipitate a relapse.

2. Support is available to help family members meet their own needs.

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Client teaching about this drug should include which instruction? 1. "Discontinue this medication after you've been seizure-free for 2 weeks." 2. "Don't drive a car or operate machinery while taking this medication." 3. "Schedule follow-up visits with your physician for blood tests." 4. "Be aware that this drug may make your heart beat faster."

3. "Schedule follow-up visits with your physician for blood tests."

A nurse is caring for a client diagnosed with bulimia nervosa. The most appropriate initial goal for this client is to: 1. avoid shopping for large amounts of food. 2. control eating impulses. 3. identify a connection between anxiety and eating behaviors. 4. restrict eating to three meals per day.

3. identify a connection between anxiety and eating behaviors.

A client is newly diagnosed with Alzheimer's disease. When planning this client's care, the nurse should focus on: 1. helping the client recognize his physical limitations. 2. helping to reverse the disease. 3. providing a safe, structured environment. 4. preventing loss of the client's cognitive functions.

3. providing a safe, structured environment.

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? 1. The type of anticonvulsant prescribed to manage the epileptic condition 2. Recent stress level 3. Recent weight gain and loss 4. Compliance with the prescribed medication regimen

4. Compliance with the prescribed medication regimen

A couple is speaking with a nurse about their ambivalence about sending their adult son with schizophrenia to residential placement. They tell the nurse that neither keeping their son at home nor sending him to a facility is a satisfactory solution for them. What should the nurse keep in mind when planning to discuss this situation with the family? Select all that apply. 1. Implementing what's best for the couple 2. Consulting the legal system for information 3. Suggesting a psychiatric evaluation for the son 4. Investigating all potential care options 5. Reviewing the client's treatment history

4. Investigating all potential care options 5. Reviewing the client's treatment history

A client with anorexia nervosa tells a nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to promote the client's receptivity to treatment? 1. Avoid discussing the client's distorted perceptions and feelings. 2. Focus discussions on food, body weight, and body image. 3. Discussing unrealistic cultural standards regarding weight. 4. Provide objective data and feedback regarding the client's weight and attractiveness.

4. Provide objective data and feedback regarding the client's weight and attractiveness.

When teaching a client with bulimia nervosa about possible complications, which condition should the nurse emphasize? 1. Allergies 2. Cancer 3. Diabetes mellitus 4. Hepatitis A

DM

A 70-year-old client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis, which objective is most appropriate? 1. Maintaining protein levels 2. Maintaining vitamin levels 3. Promoting weight-bearing exercises 4. Promoting range-of-motion (ROM) exercises

weight bearing exercises

When caring for a client with trigeminal neuralgia, which intervention has the highest priority? 1. Providing emotional support while the client adjusts to changes in his physical appearance 2. Monitoring intake and output 3. Assisting with ambulation 4. Encouraging the client to bathe with care

4. Encouraging the client to bathe with care

A nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions are appropriate for this client? Select all that apply. 1. Elevating the head of the bed 90 degrees 2. Loosening constrictive clothing 3. Using a fan to reduce diaphoresis 4. Assessing for bladder distention and bowel impaction 5. Administering antihypertensive medication 6. Placing the client in a supine position with legs elevated

1. Elevating the head of the bed 90 degrees 2. Loosening constrictive clothing 4. Assessing for bladder distention and bowel impaction 5. Administering antihypertensive medication

An Alzheimer's client has difficulty following instructions but listens intently when he hears the voice of a nurse, who is his primary caregiver. The physician orders an electrocardiogram (ECG) to ascertain cardiac status. The client becomes agitated when the ECG technician enters the room. What is the nurse's best course of action? 1. Assure the client that he's safe and explain the purpose of the procedure in simple terms. 2. Ask the client to try to understand what's going to happen. 3. Offer the client a sedative and attempt to obtain the ECG when the client is calmer. 4. Sit next to the client and provide verbal support until he calms down.

4. Sit next to the client and provide verbal support until he calms down.