exam 1 spring 16 q and a
Ankle/Brachial Index (ABI) measurement needs to detect peripheral artery disease (PAD). What is the normal range of ABI?
0.9-1.0
Which one of the following assessment finding suggests to a nurse that a patient is having TIAs?
Brief periods of unilateral weakness
The nurse caring for a patient taking Phenelzine (Nardil) for depression. The nurse is teaching the patient to avoid tyramine-enriched foods because of increased risk of:
Hypertensive crisis
Soon after beginning fluoxetine (Prozac), a patient is admitted to the emergency department with agitation and confusion. The nurse suspects which of the following?
serotonin syndrome
A pacemaker is the treatment of choice for what cardiac dysrhythmia?
Complete heart block
Which neurons transmit impulses from the CNS?
motor
The nurse is caring for a client with tetraplegia (quadriplegia) following a motor vehicle accident. A family member of the client states, "I know there is grief associated with the loss of independence, but how do I help my loved one to move past that?" the nurse is most helpful to say which of the following?
"Grief is a normal process. Let's discuss offering support throughout the process."
Which question asked by the nurse is most important initially when obtaining the medial history of patient with endocarditis?
"Have you recently been treated for strep throat?"
when a patient comes to the emergency department complaining of chest pain, which question is most important for the nurse to ask initially?
"When did your pain begin?"
Which patient is most important for the nurse to assess for complications following a cardiac catheterization?
A 75 year old with chronic kidney disease
The nurse caring for a patient who is suspected of having cardiovascular diseae has a stress test ordered. The patient has a comorbidity of multiple sclerosis (MS), so the nurse knows the stress test will be drug induced. What drug will be used to dilate the coronary arteries?
Dobutrex
What would the nurse do to best assist the client in increasing peristalsis and encouraging defecation after suffering from a neurological deficit?
Help the client to the bathroom at a particular time each day
The nurse is caring for a client with Guillian-Barre syndrome (GBS). Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds
All the following drugs belong to the group MAOI classes except:
Isocarboxazid (Marplan)
Betaxolol (Betoptic) or Timolol (Timoptic) is used in treatment of glaucoma. What is the drug mechanism of this action for either eye medication?
It decreases aqueous humor production and decrease intraocular pressure
A patient needs additional information about her heart condition. The patient states to the nurse, "What is considered the pacemaker of the heart?" The nurse response includes
It is the SA node
You are taking care of a client who is taking an anticonvulsant. What should you advise the client about discontinuing the drug abruptly?
It may trigger status epilepticus
Which of the following drug categorized under the class of Beta blockers?
Propanolol (Inderal)
Which one of the following nursing interventions is most appropriate for managing the care of a patient experiencing a seizure?
Provide oxygen during and after the seizure
QUIZ 2
QUIZ 2
The nurse is caring for a stuporous patient. Which assessment finding is documented to reflect an improvement in the patient's level of consciousness?
Somnolent
For which one of the following assessment should the nurse withhold a beta-blocker such as atenolol (Tenormin) when caring for a patient with a vascular disorder of the heart?
The patient's heart rate is 56 beats/minute
You are caring for a status post(s/p) fall patients on a skilled nursing facility (SNF) floor. Which patient goal is most appropriate for the acute phase of a neurological injury?
The patient's vital signs and LOC will stabilize returning to baseline
The nurse is talking with a newly paralyzed below waist patient and his wife. The wife is trying to raise patient's spirit and begins talking about the possibility of them having a baby. Which instruction is appropriate for the nurse at this time?
There is a reduced ability to have a baby for the patient, however you can explore all options with professionals
The nurse should question the use of conjugated equine estrogen (Vagifem) by a patient who has a history of:
Thromboembolic disease
Your patient is on methotrexate (Trexall) for the treatment of non-Hodgkin lymphoma. Which of the following instructions you should include in your teaching?
Use a soft-bristled toothbrush
A patient with a neurologic deficit has been admitted to your unit. The nurse caring for this patient is assessing the patient and observes significant changes in the patient's status. Which of the following action should the nurse perform immediately?
Use the Mini-Mental Status Examination
Which of the following is the most common clinical manifestation of sickle cell disease (SCD)?
Vaso-occlusive crisis
The nurse should assess a patient who has megaloblastic anemia for indications of which of the following vitamin deficiencies?
Vitamin B12
Which of the following drugs belong to the group NSAID? Select all that apply.
aspirin advil motrin aleve
A patient is taking alteplase (Activase) to treat acute myocardial infarction. The nurse should understand this drug is most effective when the patient receives it:
within 3 hr of symptoms onset
The nurse is talking with the mother of a client who is diagnosed with a Traumatic Brain Injury (TBI). The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction made by the nurse, is most appropriate?
"The client may be experiencing a change in affect due to the brain injury."
The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale (GCS). Which score would indicate to the nurse that the client is in a semi-comatose state?
A score of 9
You are teaching a group of students about the correct conduction of a heartbeat. Your explanation includes the conduction system of the heart beginning with the Sinoatrial node (SA node) and follows:
AV node, Bundle of his, right & left bundle branches, Purkinje fibers
You are learning about medications used in the treatments of persons diagnosed with Myasthenia Gravis. You understand that neostigmine (Prostigmin), pyridostigmine (Mestinon) and ambenonium (Mytelase) work to sustain muscle contraction and that these medications belong to what drug classification?
Anticholinesterase drugs
While assessing a client's ocular history, what would be an appropriate question for the nurse to ask the patient?
Are you having any current problems seeing?
A home care nurse is helping a client and family cope with a recent neurologic deficit. Which of the following interventions would be most important for the nurse to perform first?
Assist the client and family to identify possible solutions and goals
In developing the plan of care, which of the following will be a priority for the nursing management of a patient with a spinal cord injury at the lumbar level of the spine?
Assistance needed with ambulation
The nurse is caring for a patient with clinical depression who is receiving a Monoamine Oxidase Inhibitors (MAOIs). When providing teaching about precautions with this medication, which action should the nurse stress to the patient as important?
Avoid chocolate and aged cheese
A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?
Avoid heavy lifting
The physician's office nurse is caring for a patient who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?
Cerebral angiography
When taking a history from a patient with mitral valve prolapse, which of the following characterize the chest pain the patient experiences? Select all that apply.
Chest pain occurs without exertion Chest pain is prolonged in duration
You are caring for a patient with a damaged tricuspid valve. You know that the normal tricuspid valve is help in place by which of the following?
Chordae tendineae
The nurse is caring for four clients who have come to the clinic for eye exams. The nurse would know that which client is visually impaired?
Client B- eyes test at 20/100 and 20/200 with corrected lens
While making your rounds after coming on shift, you find a client thrashing about in bed complaining about a severe headache. The client tells you that the pain is behind the right eye which is red and tearing. What type of headache would you suspect this client of having?
Cluster
The nurse is giving report on a patient to the oncoming nurse. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC). Patient's LOC is 6 in Glasgow Coma Scale. The nurse interprets this as:
Comatose
A 24 year old female rock climber is brought to the emergency department after a fall from the face of the rock. The young lady is admitted for observation after being diagnosed with a contusion of the brain. The client asks the nurse what having contusions means. How should the nurse respond?
Contusions results in bruising, and sometimes, hemorrhage of superficial cerebral tissue
The nurse is working in a neurologist's office, performing a history and assessment on a patient experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?
Cranial nerve VIII
The nurse is assessing the throat of a patient and asking the patient to stick out the tongue. The nurse is assessing which cranial nerve in asking the patient to stick out the tongue?
Cranial nerve XII
Patient taking pramipexole (Mirapex) for Parkinson's disease needs to be tested for which of the following lab?
Creatine kinase (ck)
The nurse is caring for a patient who is taking flutamide to treat prostate cancer. The nurse should monitor for which of the adverse effects of this drug? Select all that apply.
Decreased libido Gynecomastia Impotence
Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field?
Ensure a clutter-free walkway
A patient with end-stage renal disease has a decreased red blood cell production. What medication can the nurse administer with physician's order that will increase the production of erythrocytes?
Epoetin alfa (Epogen)
A patient with aortic stenosis is most at risk for which one of the following problems?
Falls
A nurse is caring for a patient who has known sensitivity to Escherichia coli/Ecoli-derived proteins. This sensitivity is a contraindication for which of the following drugs?
Filgrastim (Neupogen)
The nurse is obtaining a patient's drug history and finds that the patient is taking lithium carbonate (Lithobid) for bipolar disorder. Which of the following findings in the patient's drug history should alert the nurse to monitor for lithium toxicity?
Furosemide (Lasix) for hypertension
A nurse is caring for a patient who is about to begin taking epoetin alfa (Epogen). Which of the following lab values should increase with effective therapy?
Hemoglobin (Hgb)
Your patient has received 2 units of whole blood today following an episode of GI bleeding. Which of the following lab would you expect post-transfusion to be checked?
Hemoglobin and hematocrit
You are teaching a group of nursing students about adventitious heart sounds. You explain that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would you tell these students about a ventricular gallop? Ventricular gallop in adult patient indicates:
Hypertensive heart disease
When reviewing the adverse effects of drug therapy with a patient, the nurse should explain that orthostatic hypotension is a common adverse reaction of which of the following drug?
Imipramine (Tofranil)
The physician orders intravenous osmitrol (Mannitol) for a client with a head injury and increased intracranial pressure. Which assessment finding would best indicate to the nurse that the client is having a therapeutic response to the medication?
Increased Glasgow coma scale (GCS)
According to the given instruction on the medication label, the only route to administer this medication is:
Intravenous (IV)
A patient is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
Mannitol (Osmitrol)
A patient is exhibiting signs of increasing intracranial pressure (IICP). Which intravenous solution (IV) would the nurse anticipate hanging?
Mannitol (Osmitrol)
The nurse is visiting a patient at his home. During assessment, patient complains of otalgia. The medical term, "Otalgia" may include which of the following? Select all that apply.
Meniere's disease Ototoxicity Otitis media and Otitis externa Cerumen impaction (earwax)
Which neurons transmit impulses from the CNS?
Motor
The nurse is performing an assessment on a patient with a suspected neck rigidity. Which method should help the nurse assess for neck rigidity correctly?
Moving the head and chin toward the chest
A nurse administers Sublimaze (fentanyl citrate) injection to a patient to reduce pain. Which of the following drug should the nurse have available to reverse the effects of fentanyl?
Naloxone (Narcan)
A patient is admitted to the emergency department with significant blood loss. The physician orders 2 units of packed red blood cells to be transfused immediately. Which blood groups would be compatible with patient's O Rh positive blood group?
O Rh+ve or O Rh-ve
The nurse knows assessing patient's motor response for a comatose patient is important. Which method may the nurse use to assess the motor response for a comatose patient?
Observing the patient's response to painful stimulus
The nurse is explaining the three layers of tissue which make up the heart wall. As the nurse draws the layers in different colors to highlight the layers, which color would the nurse use for the heart valves?
Orange, the same color as the endocardium
A 55-year-old client presents at the walk-in clinic complaining of feeling like a mask is on her face. While doing the initial assessment, the nurse observes a pill rolling movement in the right hand and a stooped posture. Physical examination shows bradykinesia and a shuffling gait. What would the nurse suspect is the causative factor for these symptoms?
Parkinson's disease
The nurse is evaluating the progression of a patient in the home setting. Which activity of the hemiplegic patient best indicates that the patient is assuming independence?
Patient grasps the affected arm at the wrist and raises it
Which of the following is correct about a drug interaction between Valproic acid (Depakote) and Phenytoin (Dilantin)?
Phenytoin toxicity
When caring for a patient who is taking risperidone (Risperdal) for schizophrenia, the nurse should monitor for which of the following adverse effects of the drug?
Polyuria
The patient is weak and drowsy after a lumbar puncture. The nurse caring for the patient knows that what priority nursing intervention should be provided after a lumber puncture
Position the patient flat for at least 3 hours
QUIZ 1
QUIZ 1
QUIZ 3
QUIZ 3
Which of the following disorder is most common in young women and characterized by periodic constriction of the arteries that supply the extremities?
Raynaud's disease
The nurse initiates a teaching plan for the family and client with neurologic deficits due to Parkinson's disease. Which nursing instruction is the highest priority?
Reduce home safety hazards
you are discharging a patient after a cardiac catheterization. What would you include in your discharge teaching?
Report any numbness, tingling, or sharp pain in the extremity
Which of the following laboratory values need to be monitored for a patient taking folic acid for the treatment of megaloblastic anemia?
Reticulocyte count
When reviewing the indications for various antidepressants, the nurse should understand that bupropion hydrochloride (Wellbutrin) is an appropriate choice for patients who have which of the following? (Select all that apply)
Seasonal affective disorder (SAD) Nicotine addiction Depression
When reviewing the medication history of your patient, you found that patient is on timolol (Timoptic). As a nurse and care giver of the patient, you should question about the use of this medication for which of the following medical condition?
Seizure disorder
Identify the heart rate and condition of a patient on the following 6 second strip? Select all that apply
Sinus Bradycardia Heart rate of 50 beats/min
Which LOC would be most correct for a nurse to document when calling a patient's name causes the patient to awaken temporarily, followed by drifting back to sleep?
Somnolent
Because of the pain in her facial muscles and jaws, a young female client with Bell's palsy is upset because she is unable to communicate properly. What advice can be given to improve her speech?
Speak slowly and in short sentences
When a nurse is asked to assist the physician with a diagnostic Romberg test, which nursing intervention is most appropriate to ensure patient safety?
Stand close to the patient in case the patient should begin to sway
What kind of diluent is required for reconstitution?
Sterile water or Normal Saline
A client is diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess in this client?
Suicidal ideations
Undifferentiated cells that migrate to the thymus gland develop into which of the following?
T lymphocytes
A nurse is caring for a patient who is taking amphetamine sulfate (Adderall) for ADHD. The nurse should monitor patient for which of the following adverse effect?
Tachycardia
A mother of an adolescent female is asking the nurse for guidelines of when her daughter should have her first and subsequent frequency of Pap test. What would be the correct response by the nurse?
The first Pap test should be no later than age 21 years and then every 3 to 5 years after ward
When you are caring for a patient with leaking cerebral aneurysm, which one of the following r equired the highest priority for the nurse to intervene?
The patient is constipated
A patient's lipid panel indicates an LDL of 182 mg/dL. Which of the following is an accurate analysis of laboratory result?
The patient's LDL is high; lifestyle changes should be encouraged
The nurse is doing discharge teaching with a client newly diagnosed with Meniere's disease. Why would the nurse advise a low-sodium diet to this client?
To reduce the production of fluid pressure in the inner ear
Which of the following is the correct order of the valves that blood circulates from the right to the left side of the heart?
Tricuspid Pulmonic Mitral Aortic
The patient with detached retina undergoes a scleral buckling procedure. Postoperatively, which patient problem should be the nurses' highest priority?
Vomiting
When caring for a patient who is receiving vincristine to treat lung cancer, the nurse should monitor for which of the following findings that indicates an adverse effect?
Weak hand grasps
You are caring a patient who is on chlorpromazine, a conventional antipsychotic drug. While teaching the patient and family members about this drug, which of the following needs to be included in your teaching?
Wear sunscreen when exposed to sunlight
The nurse is giving report on a patient to the oncoming nurse. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC). Patient's LOC is 6 in Glasgow Coma Scale. The nurse interprets this as:
comatose
A patient who has mild hemophilia A is taking desmopressin (DDAVP) to prevent bleeding. Which of the following is the adverse reaction of this drug? Select all that apply.
fluid retention edema hyponatremia
Patient is asking the nurse why she is taking both ritonavir (Norvir) and zidovudine (Retrovir) therapy for the treatment of HIV-1. The nurse should explain that the patient will receive ritonavir along with at least one reverse transcriptase inhibitor to:
prevent drug resistance
What phase of neurologic deficit begins when the client's condition is stabilized?
recovery
Patient is on transdermal conjugated estrogen and medroxyprogesterone (CombiPatch) to treat postmenopausal symptoms. The nursing teaching about the therapeutic effects of this drug includes: (Select all that apply.)
reduces the risk of ovarian cancer prevents osteoporosis relieves hot flashes
A patient's family member asks what hematopoiesis is. What should the nurse tell the family member?
the manufacture and development of blood cells
A patient had a splenectomy following a violent motor vehicle accident. The parents ask the nurse if there are any special considerations following the surgical removal of the spleen. Which of the following is the most correct response?
the patient is susceptible to infection because the spleen removes bacteria from the blood
Your patient is taking clopidogrel (Plavix) to prevent stent stenosis. The nurse should monitor patient for which of the following adverse reaction?
thrombocytopenia