Exam 1

The nurse is caring for a client who has just been told that his illness is progressing and nothing more can be done for him. After the physician leaves, the client asks the nurse to stay with him for a while. The client becomes tearful and tries several times to say something, but cannot get the words out. What would be an appropriate response?

"Do you need more time to think about this?"

A 35-year-old woman is diagnosed with peripheral neuropathy. When making her plan of care, the nurse knows to include what in client teaching? Select all that apply.

-contractures -pressure ulcers -venous thromboembolism -pneumonia

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is higher than

185 mm Hg/ 110 mm Hg

Which patients are NOT a candidate for tissue plasminogen activator (tPA) for treatment of stroke?

a patient who received heparin 24 hours ago

A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI?

I am trying to quit smoking and have a patch on

A client's most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and liver. What is the most likely mechanism by which the client's cancer cells spread?

Lymphatic circulation Lymph and blood are key mechanisms by which cancer cells spread. Lymphatic spread (the transport of tumor cells through the lymphatic circulation) is the most common mechanism of metastasis. Apoptosis is programmed cellular death.

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Maintains a patent airway

The nurse is part of the health care team at an oncology center. A client has been diagnosed with leukemia and the prognosis is poor, but the client is not yet aware of the prognosis. How can the bad news best be conveyed to the client?

The prognosis should be delivered with the client at eye level.

The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following?

approximately 60-75% of client's recover completely

You are assisting a patient who has a right side hemiparesis and dysphagia with eating. It is very important to:

check for pouching of food in the right cheek

a client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last 2 cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple transfusions, the client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia?

closely observe the clients skin for petechiae and bruising

A hospice nurse performs a follow-up telephone call to the spouse of a client who died about 1 year ago. The spouse tells the nurse, "I'm always feeling so sad. Life just doesn't feel worth living." Further conversation reveals that the spouse is having trouble sleeping and eating since her husband's death and that the spouse is "drinking more since he died." The nurse identifies which nursing diagnosis as the priority?

complicated grieving

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:

complications

Order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered:

every 3 hours after the onset of stroke symptoms

A nurse is conducting a spiritual assessment of a terminally ill client using the four step FICA process and asks the question, "What gives your life meaning?" The nurse is assessing which of the following?

faith and belief

In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson's disease and Huntington's disease is the development of ________ in clients with advanced Huntington's disease.

hallucinations and delusions

The nurse knows that interferon agents are used in association with chemotherapy to produce which effects in the client?

shorten the period of neutropenia Explanation: Interferon agents are a type of biologic response modifiers (BRMs) used in conjunction with chemotherapy to reduce the risk of infection by shortening the period of neutropenia through bone marrow stimulation. The suppression of bone marrow creates the need for interferon use, not a result of the use. Although some BRMs can inhibit tumor growth, the primary use is for reducing neutropenia. Interferon use does not replace standard cancer treatments or decrease the need for those treatments.

A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the nurse knows to include what in client teaching? Select all that apply.

- inspect the lower extremities -footwear needs to be accurately sized -assistive devices may be needed to reduce the risk of falls

which is a true statement regarding pharmacologic aspects of aging?

-altered blood flow, declining liver and renal functions, or cardiac output may affect distribution and metabolism

An emergency department nurse understands that a 110-lb (50-kg) recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the client receive?

45 mg The client is weighed to determine the dose of t-PA. Typically, two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. 50 kg X 0.9 mg= 45 mg dose

When administering medications to an older adult patient, which medication does the nurse understand may remain in the body longer due to increased body fat?

Barbiturates Explanation: Proportion of body fat increases with age, resulting in increased ability to store fat-soluble medications, including barbiturates; this causes drug accumulation, prolonged storage, and delayed excretion. The other medications listed are not fat-soluble.

The nurse is planning the care of a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon?

Decreased availability of dopamine

In the course of a focused neurologic assessment, the nurse is palpating the client's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function?

Muscle tone

The nurse is conducting a focused neurologic assessment and is assessing the client's gag reflex. How should the nurse best perform this aspect of the assessment?

lightly touch the clients pharynx with a cotton swab

A client with a recent history of GI disturbance has been scheduled for a barium study. The physician ordered this particular test for this client because it will:

show movement of the GI tract

An elderly client is hospitalized. To maintain the client's mobility, the best nursing intervention is

sit the client in chairs for meals

The following information is documented on the assessment form for an older adult: -Kyphosis -Dry mucous membranes -Decreased respiratory excursion -Urinary incontinence The nurse is reviewing the information and reports which finding to the physician?

urinary incontinence Urinary incontinence is not a normal age-related change. Kyphosis, dry mucous membranes, and decreased respiratory excursion are considered normal age-related changes.

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?

weakness on one side of the body and difficulty with speech explanation : The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.

The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?

Explaining hospice care and services

A nurse is noting from a client's neurologic assessment findings that the client's motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit?

Medulla oblongata The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord, and sensory impulses from the peripheral sensory neurons to the brain. The pons is part of the brainstem. The midbrain forms the forward part of the brainstem and connects the pons and the cerebellum with the two cerebral hemispheres. The subarachnoid space lies between the pie matter and the arachnoids membrane.

A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?

Nausea Explanation: Nausea needs to be controlled to prevent vomiting, which can greatly increase the intracranial pressure and subsequently rupture the aneurysm. Complaint of headache for past month is significant and probably attributes to the evaluation at hand. Having no bowel movement since yesterday is not significant; although, every effort should be made to prevent constipation. Frequent voiding is expected especially with the use of osmotic diuretics.

A client newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe?

Nausea and Vomiting

A transcranial Doppler ultrasonography detects cerebral vasospasms in a client experiencing lethargy 8 days following a subarachnoid hemorrhage. The nurse anticipates which therapeutic intervention?

Nimodipine PO explanation Medication may be effective in the treatment of vasospasm. Based on one theory, that vasospasm is caused by an increased influx of calcium into the cell, medication therapy may be used to block or antagonize this action and prevent or reverse the action of vasospasm if already present. The most frequently used calcium channel blocker is nimodipine. The other interventions and medications are not used to treat vasospasms.

A client presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what?

Peripheral nerve disorder

Which is an age-related change associated with the nervous system?

Postural hypotension Explanation Postural hypotension, cerebral atrophy, decreased cerebral function, and decreased nerve impulse conduction are age-related changes associated with the nervous system.

The client is scheduled for a breast lump excision and sentinel node biopsy. What should the nurse know in planning care for the client with a positive biopsy?

a wide excision of the lump will be performed

The client is 45 years old and has a family history of breast cancer. The client was diagnosed with breast cancer 2 months ago. During a routine visit, the physician prescribes dexamethasone to be taken over a 3-week period. Which symptom would prompt the physician to add dexamethasone to the client's treatment plan?

an 8 pound weight loss explanation: Dexamethasone initially increases appetite and may provide short-term weight gain in some clients. Massive swelling in the arm is indicative of edema, which occurs due to advanced nodal involvement. Radiation therapy with ionizing radiation stops cellular growth. This therapy may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present, and it can be used prophylactically to prevent spread. Other symptoms of breast cancer may include scaly skin around the nipple, skin changes, erythema, and clear, milky, or bloody discharge. These symptoms, however, will not prompt the physician to prescribe dexamethasone therapy.

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client?

impaired swallowing

Chemotherapeutic agents have which effect associated with the renal system?

increased uric acid excretion Chemotherapeutic agents can damage the kidneys because of their direct effects during excretion and the accumulation of end products after cell lysis. Urinary excretion of uric acid increases with the use of chemotherapeutic agents. Hyperkalemia, hyperphosphatemia, and hypocalcemia can occur from the use of chemotherapeutic agents.

A client with Alzheimer's disease is being admitted to the hospital for malnutrition and dehydration. What is the rationale for the nurse to place the client closer to the nurses' station?

limit wandering

What is the priority intervention in the emergency departments for a patient with a stroke?

maintenance of respiratory function with patent airway and oxygen administration

A hospice nurse is visiting the home of a client who was recently diagnosed with a terminal illness. The nurse is developing the client's plan of care and is assessing beliefs and preferences about end-of-life care. The nurse would expect to complete this assessment at which time?

over the course of several visits

The nurse is caring for a client who has just been told that her stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the client the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer?

palliative

A client has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities?

place a pillow in the axilla when there is limited external rotation

A hospice nurse is caring for a young adult client with a terminal diagnosis of leukemia. When updating this client's plan of nursing care, what should the nurse prioritize?

providing realistic emotional preparation for death

which assessment finding by the nurse and statement by an older adult would require the nurse to report suspected elder abuse

stage II decubitus ulcer on coccyx; "no one is able to turn me or lift me anymore explanation: Neglect is the most common form of elder abuse. The inability of an older adult to obtain basic care is considered neglect. If a client is not being turned or repositioned to prevent skin breakdown, then neglect is happening. A BMI of 24 is within the normal range, and the inability of the client to have his or her favorite foods would not be abuse. The client with diabetes has blood sugar within normal ranges, and the client is only expressing concern over the cost of medications; social services may need to be notified to provide help through community resources. The story provided by the older adult with the deformed arm is consistent with the injury.

The nurse is preparing to administer tissue plasminogen activator (tPA) to a patient who weighs 132 lbs. The order reads 0.9mg/kg tPA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?

5

A 50-year-old client is an alcoholic. The client has been diagnosed with pancreatic cancer and underwent surgery to remove the tumor. Despite the tumor being removed, the physician informs the client that chemotherapy needs to be started immediately. Using evidence-based practice, which intervention might the nurse expect the physician to include, with the goal of improving quality of life, mood, and median survival.

Palliative care

A client with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize?

Assessment and nutritional status explanation: Cachexia is a wasting syndrome of weight loss, muscle atrophy, fatigue, weakness, and significant loss of appetite. Consequently, nutritional assessment is paramount.

A client is experiencing anorexia and the physician is to order a medication to stimulate the client's appetite. Which of the following would the nurse least likely expect the physician to prescribe?

Atropine Atropine is used to manage excessive oral and respiratory secretions when death is imminent. Dexamethasone, megestrol, and dronabinol may be used to stimulate appetite in clients who are at the end of life.