exam 6

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include?

"Move your head slowly to decrease vertigo."

Creatinine:

0.5-0.9

BUN:

6-20

A nurse is caring for a client who is 72 hr postoperative following an above the knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?

Administer an oral dose of gabapentin to the client

A nurse is teaching a client who has a new diagnosis of simple partial seizures about aura. Which of the following statements by the client indicates an understanding of the teaching?

An aura is a sensory warning that a seizure is imminent.

A nurse is reviewing discharge instructions with a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include?

Apply a cool cloth to the face during a headache

A nurse in the emergency department is assessing a client who has myasthenia gravis. The client reports recent increasing muscle weakness and the nurse suspects the client is experiencing a myasthenic crisis. Which of the following actions is the nurse's priority?

Assist with a Tensilon test

A nurse is caring for a client who has a full arm cast and reports pain of an 8 on a scale from 0 to 10 that is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

Check the circulation of the affected extremity

A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect?

Difficulty with speech=

A nurse is performing a neurologic assessment for a client who has a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement

Dysphagia

A nurse is caring for a client who was admitted for status epilepticus and is on seizure precautions. Which of the following actions should the nurse plan to take?

Establish IV access

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

Intention tremors

A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? (Select all that apply)

Pill-rolling tremor of the fingers Shuffling gait Drooling Lack of facial expressions

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?

Place the client's bedside table on the right side of the bed.

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure?

Protect the client's head

A nurse is reinforcing teaching with a client who has Parkinson's disease and has received a prescription for bromocriptine (Parlodel). Which of the following instructions should the nurse include in the teaching?

Rise slowly when standing

A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions?

Semi-Fowler's

A nurse is teaching a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the clients medication teaching plan?

Take medications at a consistent time each day to maintain therapeutic blood levels

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure?

The client has a pacemaker

A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect?

Ulnar deviation

A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect?

Weakness of the lower extremities

A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching?

You should avoid reading for 1 week.

A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following are appropriate actions by the nurse when performing this technique? (Select all that apply)

place the client supine Place hands behind the client's nec Bend client's head toward chest

A nurse is assessing a client who has a possible head injury following a motor-vehicle crash. The nurse should recognize that which of the following findings indicates increasing intracranial pressure?

restlessness

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of instructions?

"I should call my doctor if my vision gets worse."

A nurse is providing teaching regarding a new prescription for carbidopa-levodopa for a client who has Parkinson's disease. Which of the following client statements indicates an understanding of the teaching?

"I should expect my urine to be a darker color"

A nurse is developing a plan of care for a client who is scheduled for a cerebral angiogram with contrast dye. Which of the following statements by the client should the nurse report to the provider? (Select all that apply)

"I think I may be pregnant" "I take Coumadin" "I am allergic to shrimp" "I am allergic to latex"

A nurse is providing teaching for a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements by the family indicates an understanding of the teaching?

"The drugs used to treat Alzheimer's disease can help delay cognitive changes"

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching?

"Try to stay awake most of the night prior to the procedure"

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect? (Select all that apply)

1. Crepitus with joint movement 2. Decreased range of motion of the affected joint 3. Joint pain that resolves with rest

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching?

A TIA can precede an ischemic stroke.

A nurse is assessing a patient for changes in the level of consciousness using the Glasgow Coma Scale. The patient opens his eyes when spoken to, speaks inappropriate words, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document?

A) E3 +V3 + M5 = 11

A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? Select all that apply.

A) Provide privacy B) Ease the client to the floor if standing C) Move furniture away from the client D) Loosen the client's clothing E) Protect the client's head with padding

Which of the following are appropriate interventions of a patient with meningitis at risk for increased ICP? (SATA)

A) Turn off room lights and television B) Administer prescribed broad spectrum antibiotics after blood cultures are obtained C) Instruct the patient to maintain bed rest in a flat position for several hours following lumbar puncture Implement seizure precautions

A nurse is completing discharge teaching to a patient who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching?

A) You should place a magnet over the implantable device when you feel an aura occurring

A nurse is caring for a client post-lumbar puncture who reports a throbbing headache when sitting upright for meals. Which of the following are appropriate actions by the nurse? (Select all that apply)A. Use the Glasgow Coma Scale when assessing the client

Assist client to eat meals while lying flat in bed Administer an opioid medication Encourage client to increase fluid intake

A nurse is caring for a client who has Parkinson's disease and displays signs of bradykinesia. Which of the following is an appropriate action by the nurse?

Assist with hygiene as needed

A nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching?

Avoid sudden movements

A nurse is caring for a client in balanced suspension skeletal traction who reports intermittent muscle spasms. Which of the following actions should the nurse take first?

Check the position of the weights and ropes

A nurse is assessing a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations?

Cheyne-Stokes

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?

Clear drainage from the nose

A nurse in a provider's office is obtaining a nursing history from a client who has cluster headaches. Which of the following are expected findings? (Select all that apply)

Client is experiencing altered sleep-wake cycle Headache occurs at approximately the same time of the day nasal congestion and drainage occur

A nurse is performing a pain assessment on a postoperative client. Which of the following should the nurse use to determine the severity of the client's pain?

Client's report of pain on a pain scale

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching?

Darken the lights

A nurse is teaching a client who has myopia about laser-assisted in situ keratomileusis (LASIK) surgery. The nurse should include in the teaching that which of the following is an adverse effect of LASIK surgery?

Dry eyes

A nurse is providing teaching to the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is the priority?

Dysphagia

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level CS. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first?

Elevate the head of the client's bed

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?

Elevated protein

True or false, An ischemic stroke on the left side of the brain will cause left-sided weaknesses?

False

A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?

Feeling of fullness in the ear

A nurse is caring for a client who has a retinal detachment. Which of the following reports about the affected eye should the nurse expect?

Flashes of bright light

A nurse is planning care for a client who has dysphagia and has a new dietary prescription. Which of the following should the nurse include in the plan of care? (select all that apply)

Have a suction equipment available for use Use thickened liquids. Place food on the client's unaffected side of her mouth. Teach the client to swallow with her neck flexed.

A nurse in a client is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan (Zomig). Which of the following statements by the client indicates understanding of the teaching?

I should take this medication as soon as I notice symptoms developing

A nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instruction?

I will avoid bending over

A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?

Implement droplet isolation precautions

A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following are appropriate nursing actions? (Select all that apply)

Implement seizure precautions Turn off room lights and television Monitor for impaired extraocular movements

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (select all that apply)

Impulse control difficulty Left hemiplegia Loss of Depth perception Lack of awareness

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

Impulsive behavior

A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?

Inability to recognize familiar objects

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?

Infection

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter for ICP monitoring. The nurse should monitor the client for which of the following complications?

Infection

A nurse in an emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images indicates a comminuted fracture?

Injury that cause the bone to fragment into several pieces

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching?

Instill a diluted alcohol solution into the ear after swimming

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the clinical findings of migraine headaches?

Is there a pattern of headaches among family members?

A nurse is assessing a client who is admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment data the nurse should collect to determine a change in the client's neurologic status?

Level of consciousness

A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease (AD). Which of the following information should the nurse include in the teaching?

Limit choices offered to the client

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority?

Maintain a PaCO2 of approximately 35mm Hg

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?

Monitor pulse oximetry findings

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside table

Oral-nasal suction equipment

A nurse in the emergency department is assessing a client who reports sudden, severe eye pain with blurred vision. The provider determines the client has primary angle-closure glaucoma. Which of the following medications should the nurse administer?

Osmotic diuretics via IV bolus

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply)

Provide an emesis basin at the bedside Administer antipyretic medication as prescribed Perform a skin assessment

A nurse is caring for a client who displays signs of stage 3 Parkinson's disease. Which of the following actions should the nurse include in the plan of care?

Record diet and fluid intake daily Offer nutritional supplements between meals

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt, the nurse should take which of the following actions?

Remind the client to look consciously at both sides of his meal tray

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia?

Report of a headache

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods?

Salted cashews

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations?

Severe eye pain

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (select all that apply).

Speak to the client at a slower rate Assist the client to use flash cards with pictures Give Instructions one step at a time

A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI?

Specific gravity

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?

Stroke the client's inner thigh

A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect?

Swelling behind the affected ear

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample?

The client rigidly extends his arms

A nurse is assessing a client who has a closed head injury and has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?

The client's serum osmolarity is 310 mOsm/L.

A nurse is providing teaching for a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?

The nurse should teach the client to sit with the hips at a 90 degree angle or less with the knees slightly lower than the hips to avoid hip dislocation

A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with

The vaccine is recommended for adolescents before starting college

A nurse is providing teaching for a client who is prescribed alendronate (Fosamax) for osteoporosis. Which of the following information should the nurse include in the teaching?

This medication should be taken before breakfast and in an upright position maintained for 30 minutes

A nurse in the emergency department is caring for a client after suddenly losing consciousness and falling in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer?

Tissue plasminogen activator

A nurse is providing education to a patient who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching?

Try to stay awake most of the night prior to the procedure

A nurse is instructing assistive personnel on proper care of a client who has had a total hip arthroplasty. Which of the following instructions should the nurse include?

Use an abductor pillow between the client's legs when turning the client

A nurse is assessing a client who has sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?

Widened pulse pressure

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?

cap refill every four hours

A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestations of ALS?

weakness of the distal extremities

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following information should the nurse include in the teaching? (Select all that apply.)

· Driving can be dangerous due to loss of peripheral vision Laser surgery can help reestablish the flow of aqueous humor