ATI Quiz WK 6 Nur 242
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report -loss of central vision. -having a loss of peripheral vision. -seeing bright flashes of light and floaters. -having a decreased ability to perceive colors.
having a decreased ability to perceive colors. Symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive colors.
A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? -Insert a padded tongue blade into the client's mouth. -Place a pillow under the client's head. -Gently restrain the client's extremities. -Apply a face mask for oxygen administration.
Place a pillow under the client's head. The nurse should place a small pillow or other soft padding under the client's head to protect the client from injury during the seizure, and turn his head to the side to keep the airway clear.
A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? -Check the client for a fecal impaction. -Examine the client for areas of skin breakdown. -Check the client's bladder for distention. -Place the client in a sitting position.
Place the client in a sitting position. The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertension.
A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take? -Prepare the client for mechanical ventilation. -Administer an anticholinesterase medication. -Instruct the client to perform the pursed lip breathing. -Prepare to administer a vasoconstrictor.
Prepare the client for mechanical ventilation. The client who is experiencing a myasthenic crisis is at risk for loss of adequate respiratory function. The nurse should closely monitor the client's respiratory status and prepare for possible mechanical ventilation.
A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? -Reduce edema of the brain. -Provide fluid hydration. -Increase cell size in the brain. -Expand extracellular fluid volume.
Reduce edema of the brain. An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream.
A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? -"Turn the screws on the device once each day." "The purpose of this device is to immobilize the cervical spine." "Apply talcum powder under the vest to limit friction." "The purpose of this device is to allow for neck movement during the healing process."
"The purpose of this device is to immobilize the cervical spine." A client who has an injury to the cervical spine can have a halo fixation device to provide immobilization of the head and neck for a period of 8 to 12 weeks.
A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include? -"Bloodshot eyes on the day of surgery should be reported to the provider." -"Warm compresses should be applied to the eye three times daily." -"Photophobia is expected for 2 to 3 days." -"Vision will be greatly improved on the day of surgery."
"Vision will be greatly improved on the day of surgery." Vision should be greatly improved on the day of surgery. This information should be included in the teaching.
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take? -Teach controlled coughing and deep breathing. -Provide a brightly lit environment. -Elevate the head of the bed 20°. -Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day.
Elevate the head of the bed 20°. The nurse should elevate the head of the bed less than 25° to promote reduction of intracranial pressure.
A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III? -Instruct the client to look up and down without moving his head. -Observe the client's ability to smile and frown. -Have the client stand with eyes his closed and touch his nose. -Ask the client to shrug his shoulders against passive resistance.
Instruct the client to look up and down without moving his head. The nurse should observe the client's extraocular eye movements by instructing him to look at the cardinal fields of gaze as part of an evaluation of the function of cranial nerve III (Oculomotor).
A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority? -Intracranial pressure -Serum electrolytes -Temperature -Respiratory status
Respiratory status When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respirations, noting the rate and pattern, and evaluating arterial blood gases. Following intracranial surgery, even slight hypoxia can worsen cerebral ischemia.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? -Severe headache -Bradycardia -Blurred vision -Oriented to person, place, and year
Severe headache The nurse should expect a client who has meningitis to manifest a severe headache due to meningeal inflammation.
A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? -Decreased level of consciousness -Tachypnea -Bilateral weakness of extremities -Hypotension
Decreased level of consciousness As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness, decrease. Other manifestations include severe headache, irritability, and pupils that are slow to react or are unreactive to light.
A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign? -Pinpoint pupils -Jerking contractions of the head and neck -Pronation of the arms -Dorsiflexion of the great toe
Dorsiflexion of the great toe Dorsiflexion of the great toe and fanning of the other toes when the plantar reflex is assessed is an indication of a Babinski's sign, an abnormal response that indicates CNS pathology.
A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client? -Narrowing pulse pressure -Drainage of clear fluid from the ears -Alternating periods of alertness and unconsciousness -Extensive bruising in the mastoid area
Alternating periods of alertness and unconsciousness Alternating periods of alertness and unconsciousness is a common manifestation of an epidural hematoma.
A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis? -Developing a respiratory infection -Taking too much prescribed medication -Diet high in protein -Not exercising enough
Developing a respiratory infection The most common triggers of myasthenic crises are respiratory infection, not taking, or taking too little, of the prescribed medication, surgery, and high environmental temperatures.
A nurse is planning care for a client who states he is anxious concerning abdominal surgery. Which of the following actions should the nurse take? -Explain to the client that all patients feel that way prior to surgery. -Suggest the client talk to the provider. -Ask the client what to expect tomorrow. -Encourage the client to express negative emotions.
Encourage the client to express negative emotions. The nurse is acknowledging the client's negative emotions, therefore providing open therapeutic communication.
A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client -displays compulsive and ritualistic behaviors. -reminisces about the past. -makes up stories when he is unable to remember actual events. -refuses to leave home to see a provider.
makes up stories when he is unable to remember actual events. Confabulating is filling in gaps in memory by fabrication. A client who has dementia may do this unconsciously to cover for and decrease anxiety about memory gaps.
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take? -Obtain a culture of the specimen using sterile swabs. -Allow the drainage to drip onto a sterile gauze pad. -Suction the nose gently with a bulb syringe. -Insert sterile packing into the nares.
Allow the drainage to drip onto a sterile gauze pad. The nurse should allow the drainage to drip onto a sterile gauze pad in order to assess for the presence of cerebrospinal fluid. This intervention allows for the collection of data without increasing the risk for further injury.
A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.) -Muscle distortion -Pain behind the ear -Hearing loss -Facial twitching -Impaired taste
Muscle distortion is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes muscle distortion that gives the affected side a drooping appearance. Pain behind the ear is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes pain behind the ear, in the face, and in the eye on the affected side. Impaired taste is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes impaired taste, as well as difficulties with speech and eating.
A nurse is teaching a client who is preoperative how to do deep-breathing exercises and cough effectively after surgery. Which of the following statements by the client indicates an understanding of the teaching? -"I'll splint my incision with a pillow to cough." -"I'll ask for pain medication after I do the exercises." -"I'll use the incentive spirometer when I can get out of bed." -"I'll breathe deeply and cough every 4 hours."
"I'll splint my incision with a pillow to cough." The client should use a pillow to splint the incision to reduce the pain and discomfort of coughing.
A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. Which of the following statements should the nurse include in the teaching? -"Take this medication with an antacid to reduce gastric irritation." -"You may experience drowsiness while taking this medication." -"You should take this medication with meals." -"You may continue to breastfeed while taking this medication."
"You may experience drowsiness while taking this medication." The nurse should instruct the client that drowsiness can occur while taking this medication and to exercise caution while performing activities that require alertness.
A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? -Pruritus -Hypertension -Bradykinesia -Xerostomia
Bradykinesia The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.
A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action? -Document the amount of drainage. -Obtain a culture of the drainage. -Check the drainage for glucose. -Notify the client's provider.
Check the drainage for glucose. A potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage. Fluid leakage from the nose is a sign that this complication has occurred. The first action the nurse should take using the nursing process is to assess the drainage for the presence of glucose, which would indicate that the drainage is CSF.
A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? -Hypotension -Tachycardia -Irritability -Tinnitus
Irritability The nurse should monitor the client for behavioral changes, such as confusion, restlessness, and irritability as manifestations of increased intracranial pressure.
A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following action should the nurse take? -Provide the client with water to test the gag reflex. -Perform carotid massage. -Notify emergency management services. -Drive the client to the nearest medical facility.
Notify emergency management services. The client is exhibiting manifestations of a stroke and a rapid diagnosis is vital to administering appropriate treatment; therefore, the nurse should call the emergency management services.
An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? -Extension of the arms -Pronation of the hands -Plantar flexion of the legs -External rotation of the lower extremities
Plantar flexion of the legs Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tracts.
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? -Perform passive range of motion on each extremity. -Monitor the client's electrolyte levels. -Suction saliva from the client's mouth. -Record the client's intake and output.
Suction saliva from the client's mouth. The unconscious client is unable to independently maintain a clear airway and is at risk for ineffective airway clearance. According to the safety and risk reduction priority setting framework, maintaining the client's airway, breathing, and circulation is the highest priority.
A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client? -"Do have a history of chronic alcohol abuse?" -"Have you had a recent influenza infection?" -"Have traveled overseas recently?" -"Are you taking a multivitamin?"
"Have you had a recent influenza infection?" The nurse should ask the client about a recent Haemophilus influenzae infection. The cause of GBS is unknown, but it usually follows a viral infection.
A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? -"Wear an eye patch on the right eye at all times." -"Plan to relax in a hot tub spa each day." -"Engage in a vigorous exercise program." -"Implement a schedule to include periods of rest."
"Implement a schedule to include periods of rest." The nurse should assist the client in developing a schedule that includes periods of exercise followed by periods of rest to maintain muscle strength and coordination.
A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make? -"Yes, you are free to move around as you wish." -"No, you are on strict bedrest and must not be up." -"Please ring for assistance when you wish to get out of bed." -"We will have to get a prescription from your provider."
"Please ring for assistance when you wish to get out of bed." This response is appropriate. With assistance, the client can ambulate safely. Tinnitus, one-sided hearing loss, and vertigo are all manifestations of Ménière's disease that can increase the client's risk of falls when ambulating.
A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? -"Without treatment, glaucoma can cause blindness." -"Double vision is a common symptom of glaucoma." -"Glaucoma is caused by inadequate production of fluid within the eye." -"Use of eye drops will improve vision over time."
"Without treatment, glaucoma can cause blindness." The nurse should explain that without treatment glaucoma can result in blindness due to irreversible damage to the retina and optic nerve.
A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following interventions should the nurse take? -Elevate the head of the bed to 30°. -Notify the provider for drainage greater than 80 mL/8hr. -Place the client in a flat, lateral position. -Provide passive range-of-motion exercises to the neck.
Elevate the head of the bed to 30°. The client who has surgery to treat a supratentorial brain tumor is at risk for increased intracranial pressure (ICP). Elevation of the head of the bed to 30° assists in promoting venous and CNS fluid drainage from the head to prevent increased ICP.
A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care? -Obtain IV access. -Keep the lights on when the client is sleeping. -Place the client's bed in the high position. -Keep a padded tongue blade available at the client's bedside.
Obtain IV access. The nurse should obtain IV access as a precaution so the client can receive IV medications in the event of a seizure.
A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? -Provide client supervision. -Limit client physical activity. -Speak loudly to the client. -Leave the television on continuously.
Provide client supervision. Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment.
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? -The client can follow simple motor commands. -The client is unable to make vocal sound. -The client is unconscious. -The client opens his eyes when spoken to.
The client opens his eyes when spoken to. A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.
A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate? -Fresh fish -Cheddar cheese -Cherries -Chicken
Cheddar cheese The nurse should eliminate aged cheeses from the diet of a client who is prescribed selegiline. Cheddar cheese contains tyramine, which can cause a hypertensive crisis.
A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The client reports being nervous about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings? -Call the anesthesiologist to sedate the client. -Notify the surgeon of the client's food and fluid consumption. -Witness the surgical consent. -Document the findings in the client's medical record.
Document the findings in the client's medical record. Whenever a nurse collects data from a client, documentation is essential. However, in this case, all these findings are expectations for a client who is preoperative, so there is no need for the nurse to take any action other than documenting.
A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take? -Monitor sensory perception of the lower extremities. -Assist the client into a knee-chest position to manage postoperative discomfort. -Maintain strict bed rest for the first 48 hr postoperative. -Position the client in a high-Fowler's position if clear drainage is noted on the dressing.
Monitor sensory perception of the lower extremities. The nurse should perform neurologic assessments focusing on sensory perception of the lower extremities every 4 hr. Any decrease in sensation by the client requires immediate notification of the provider.
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate? -Observe for the presence of Kernig's sign. -Perform a Romberg's test. -Check the function of cranial nerve V. -Inspect for the presence of clubbing.
Perform a Romberg's test. The nurse should perform a Romberg's test to check the client's ability to maintain an upright position without swaying when standing with feet close together, with eyes open and with eyes closed. The nurse must stand close enough to prevent the client from falling.
A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider? -Pulse oximetry changed from 98% to 96% -Client reports knee pain, changed from 4/10 to 6/10 -Systolic blood pressure changed from 140 mm Hg to 120 mm Hg -Temperature changed from 37.2° C (99.0° F) to 37.5° C (99.5° F)
Pulse oximetry changed from 98% to 96% SpO2 of 96% is well above the critical level of 91% and does not warrant notifying the provider. It likely represents shallow respirations and should be continually monitored.
A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan? -Apply restraints. -Administer opioids. -Darken the room. -Reduce stimuli.
Reduce stimuli. The nurse should reduce stimuli by decreasing the number of visitors, speaking calmly, and creating a quiet environment.
A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching? -Take ibuprofen for eye discomfort. -Creamy white drainage is an indication of infection. -Notify the provider immediately if the operative eye itches. -The client should wear dark glasses while outdoors.
The client should wear dark glasses while outdoors. The nurse should instruct the client and his spouse that he should wear dark glasses when outside or in bright light until pupil reaction returns.
A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following are realistic goals? -The client will verbalize an understanding of the mode of disease transmission. -The client will experience a weight gain of one to two pounds per week. -The client will increase attendance at community social activities. -The client will receive medication to minimize episodes of breakthrough pain.
The client will receive medication to minimize episodes of breakthrough pain. The client should receive medication to minimize episodes of breakthrough pain as a goal for the end of life care.
A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings? -Nuchal rigidity -Pupils reactive to light -Widened pulse pressure -Elevated temperature
Widened pulse pressure A widened pulse pressure is a manifestation of increased ICP. Other manifestations include bradycardia, vomiting, and decreased level of consciousness.
A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? -Encourage brief exercise before meals to promote appetite. -Place food in the affected side of the mouth. -Encourage the client to take small bites. -Place the client with the head reclined back to facilitate swallowing.
Encourage the client to take small bites. The family members should encourage the client to take small bites and chew food thoroughly in order to prevent choking.
A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first? -Evaluate the client's neurological status. -Perform a complete blood count. -Check the client's temperature. -Administer an oral analgesic.
Evaluate the client's neurological status. Manifestations of a headache and stiff neck (nuchal rigidity) are indications that the client might have meningitis. The greatest risk to the client is injury from increased intracranial pressure, which can lead to brain herniation and death. Therefore, the nurse should complete a neurological assessment as a baseline. If the client does have meningitis, neurological checks should be completed every 2 to 4 hr.
A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take? -Place the client in protective isolation. -Minimize environmental stimuli. -Elevate the head of the client's bed 45°. -Limit the client's ambulation to once a day.
Minimize environmental stimuli. A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation that could cause anxiety, such as noise or bright lights.
A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? -Place suction equipment at the client's bedside. -Apply an eye patch to the client's right eye. -Avoid the use of warm water to wash the client's face. -Provide range-of-motion exercises to the client's neck and shoulders.
Place suction equipment at the client's bedside. Cranial nerves IX (glossopharyngeal) and X (vagus) innervate the muscles of the soft palate, larynx, and pharynx. Impairment of these nerves places the client at risk for aspiration, making it necessary for the nurse to have access to suction for the client.
A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? -Administer a nitrate antihypertensive. -Assess the client for bladder distention. -Place the client in a high-Fowler's position. -Obtain the client's heart rate.
Place the client in a high-Fowler's position. The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse's initial action should be to place the client in a high-Fowler's position to assist in providing immediate reduction in blood pressure and intracranial pressure.
A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.) -Provide a suction setup at the bedside. -Elevate the side rails near the head when the client is in bed. -Place the bed in the lowest position. -Keep an oxygen setup at the bedside. -Furnish restraints at the bedside.
Provide a suction setup at the bedside is correct. The nurse should provide a suction setup at the bedside to provide oral suctioning as needed following the seizure to prevent aspiration. Elevate the side rails near the head when the client is in bed is correct. The nurse should raise the side rails near the head of the bed to help keep the client in the bed. The nurse should check the facility policy for specific guidelines because raising all side rails can be considered a restraint. Elevate the rails of the bed to prevent a fall during a seizure. Place the bed in the lowest position is correct. The nurse should place the bed in the lowest position to prevent injury if a fall should occur during a seizure. Keep an oxygen setup at the bedside is correct. The nurse should monitor the client's oxygen saturation during a seizure and provide supplemental oxygen as prescribed.
