Illness Exam #2 Socrative
Which test involved a dye to be injected in the spinal column and x-ray images taken of it? 1. computed tomography 2. electromyography 3. myelogram 4. nerve conduction studies
3
a nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence 1. stress 2. urge 3. overflow 4. reflex
3
a nurse is reviewing the lab test results from a client who has prerenal acute kidney injury. Which of the following electrolyte imbalances should the nurse expect? 1. hyperkalemia 2. hypernatremia 3. hypercalcemia 4. hypophosphatemia
1
after assessing a client with ALS, the nurse finds that the oral communication of the client is impaired. Which should the nurse document in the client's medical record? 1. dysarthria 2. motor neuron death 3. muscle weakness 4. respiratory muscle weakness
1
after teaching a client who has stress incontinence, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? 1. I will limit my total intake of fluids 2. i must avoid drinking alcoholic beverages 3. I must avoid drinking caffeinated beverages. 4. I shall try to lose about 10 % of my body weight
1
anticholinergics are used to reduce tremors and drooling associated with Parkinson's disease. Which side effect of this drug contraindicates it for older clients? 1. memory impairment 2. urinary frequency 3. N/C 4. Disorders of impulse control
1
nurse is caring for the pt receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take? 1. check the results of the client's most recent CBC 2. assess the client for a hypersensitivity reaction 3. recaluate the client for hypercalcemia 4. examine the client for hepatomegaly
1
the nurse is assessing a pt who has a family hx of type II DM. Which of the findings if identified in this pt would require follow-up by the nurse? the patient has... 1. a new prescription for levothyroxine for hypothyroidism 2. decreased his waist-to-hip ratio through dietary changes 3. delivered a baby that weighed 8 lbs. 12 oz 4. a fasting blood glucose level of 100 mg/dL
1
the pt. is diagnosed with trigeminal neuralgia. Which therapy is the first-line choice for this patient? 1. antiepileptic such as gabapentin 2. muscle relaxant such as baclofen 3. percutaneous steriotactic rhizotomy 4. microvascular decompressoin
1
what is the priority diagnosis for atonic seizures 1. risk for injury r/t falls 2. ineffective tissue perfusion r/t neuromuscular dysfunction 3. acute confusion r/t postictal state 4.activity intolerance r/t a-tonicity of muscles
1
which assessment finding corresponds with the first stag of Parkinsons disease? 1. upper extremity tremors 2. muscle rigidity 3. shuffling gait 4. postural instability
1
which assessments should be performed to rpevent intrarenal damage from postrenal causes in clients with acute kidney injuries? 1 examination of prostate 2. measurement of blood volume 3. measurement of cardiac output 4. id of nephrotoxins
1
which condition leads to panhypopituitarism? 1. reduce secretion of all hormones from the hypothalamus 2. reduced secretion of a hormone fro the anterior pituitary gland 3. reduced secretion of a hormone from the hypothalamus 4. reduced secretion of thyroid hormones
1
Which interventions should the nurse implement for a client with Parkinson's disease? Select all that Apply 1. elevate head of bed when eating and drinking 2. arrange speech therapy for the client 3. teach the client to take long steps while walking 4. teach the client to call the healthcare provider for medical compliance 5. discuss and evaluate the client's ability to drive
1 2 4 5
the pt with increased ICP to to receive iv mannitol in the acute unit. Which nursing actions are instituted with administration of this drug? 1. draw up the drug through a filtered needle 2. insert a foley catheter to measure strict urine output 3. monitor serum and urine osmolality on a weekly basis 4. assess for acute renal failure, weakness or edema 5. admin mannitol through a filter in the IV tubing
1 2 4 5
A nurse is caring for a client who has undergone surgery for a spinal tumor. Which complications are most commonly seen in clients after this type of surgery? Select all that apply 1. meningitis 2. sexual dysfunction 3. loss of bladder or bowel function 4. decreased sensitivity to pain, heat of cold 5. hematoma
1 2 5
which is true regarding hypopituitarism? Select all that apply 1. it is the result of hypersecretion of hormones for the anterior pituitary gland 2. it is controlled with hormone replacement therapy 3. it is often related to a hypersecreting tumor 4. it may lead to headaches and visual changes 5. it is found to have a genetic association
1 3 4 5
Nurse it caring for a healthy patient who has a serum glucose of 60. The nurse anticipates which of the following counter-regulatory serum hormonal changes are likely to occur in this patient? Select all that apply 1. increased epinephrine levels 2. decreased glucocorticoid levels 3. increased insulin levels 4. decreased thyroxine level 5. increased GH levels
1 5
Which are the clinical manifestations of ALS? Select all that apply 1. double or blurred vision 2. difficulty swallowing 3. fasciculation 4. tremor 5. memory loss
2 3
A nurse is providing teaching to a client who has a new diagnosis of type 2 DM. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? Select all that apply 1. Polyuria 2. blurred vision 3. polydipsia 4. tachycardia 5. moist, clammy skin
2 4 5
the neurologist orders 500 mg methylprednisolone IV daily. What do you need to do to administer this medication safely? Select all that apply. 1. reconstitute with 8 ml of benzyl alcohol 2. administer a total dose of 8 mL of reconstituted solution 3. use the solution within 60 minutes of reconstitution 4. begin the medication infusion before 0900 each day 5. deliver the dose over 30 minutes using IV pulse administration
2 4 5
The RN is teaching nursing students about monitoring for clinical manifestations when assessing spinal shock in a client. Which statement made y the nursing student indicates effective teaching? Select all that apply. 1. the client would have low urine output 2. the client would have improper digestion 3. the client would have low BP 4. the client would have a decreased HR 5. The client would not show reflexes if tapped on the knee."
2 5
intracranial hemorrhage
may cause medulla oblongata to be wedged into foramen magnum by pressure of blood
subdural hematoma
may present as acute, subacute or chronic
HHS
nonketotic
epidural hematoma
occurs between the skull and dura
spastic cerebral palsy is characterized by which of the following? 1. athetosis, dystonic movements 2. tremors, lack of active movement 3. hypertonicity; poor control of posture, balance, and coordinated motion 4. Wide-based gait; poor performance of rapid, repetitive movements
3
The nurse is caring for a client with hypopituitarism from a lack of adrenocorticotropic hormone (ACTH). Which complication is most likely to occur in this client? 1. circulatory collapse 2. osteoporosis 3. water retention 4. cervical retraction
1
nurse is caring for a pt who was admitted for a diagnosis of meningococcal meningitis. Which nursing action is specific to this type of meningitis 1. administer an antifungal agent such as amphotericin B 2. observe the patient for genital lesions 3. Put in protective isolation
3
A 12-year-old child with Guillain-Barré syndrome is admitted to the pediatric intensive care unit. She tells you that yesterday her legs were weak and that this morning she was unable to walk. After the nurse determines the current level of paralysis, the priority assessment includes 1. swallowing ability 2.parental involvement 3. level of consciousness 4. antecedent viral infections
1
A young boy has just been diagnosed with pseudohypertrophic (Duchenne's) muscular dystrophy. The management plan should include: 1 Recommending genetic counseling. 2. Explaining that the disease is easily treated. 3. Suggesting ways to limit the use of muscles. 4. Assisting the family in finding a nursing facility to provide his care.
1
The nurse is reviewing the biographic data and history for the patient with myasthenia gravis. What does the nurse expect to see included in the patient's record? 1. muscle weakness that increases with exertion or as the day wears on 2. difficulty sleeping with early morning waking and restlessness 3. confusion and disorientation in the late afternoon 4. muscle pain and cramps that interfere with activities of daily living
1
a nurse is assessing the MRI report of 4 clients with renal trauma. Which client requires priority treatment? 1. client with a thrombus in the renal artery or vein 2. client with nonexpanding hematomas and superficial lacerations 3. client with injuries of the renal artery or vein with controlled hemorrhage 4. client with lacerations 1.2 cm deep, but not involving the collecting system
1
a nurse is caring for a newborn who has myelomeningocele. Which fo the following nursing goals has the priority in the care of this infant? 1. maintain the integrity of the sac 2. promote maternal-infant bonding 3. educate the parents about the defect 4. provide age-appropriate stimulation
1
A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor? 1. hypermagnesemia 2. hypokalemia 3. hyperkalemia 4. hypomagnesemia
2
A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 DM. Which of the following instructions should the nurse include in the teaching? 1. test your blood glucose level every 8 hours 2. check your urine for ketones when blood glucose levels are greater than 240 mg/dL. 3. withhold your usual daily dose of insulin 4. drink 240-360 mL of calorie-free liquids every 8 hours
2
In planning care for the patient with increased ICP what does the nurse do to minimize ICP? 1. gives the bath, changes the linens and does passive ROM exercises to hand/fingers and then allows the pt to rest 2. gives the bath, allows the pt. to rest, changes the linens, allows the pt to rest, and then performs passive ROM exercises to hands/fingers 3. defers the bath, changes the linens and does passive ROM exercises to extremities until the danger of increased ICP has passed 4. Contacts the physician for specific orders about all activities related to the care of the patient that may cause increased ICP
2
The clinical manifestations of encephalitis are the same as those of meningitis. Which characteristic feature helps identify encephalitis? 1. it involves pathogens that invade the CNS 2. It involved the cerebrum, brainstem, and cerebellum 3. it can be a life-threatening emergency leading to increased cranial pressure, coma, and death 4. it is diagnosed by examining the cerebrospinal fluid
2
The nurse is caring for the patient with T 1DM. The patient reports feeling a sensation of nausea and states that he has had one episode of vomiting in the past tow hours. The patient states that he does believed he should take the scheduled morning based on his symptoms. What action by the nurse is best at this time? 1. contact physician 2. explaining the need to take the insulin 3. document the refusal and continue on with the planned care 4. check the patient's fasting serum glucose level
2
The nurse is providing teaching to a group of pts who are planning to participate in an athletic triathlon. Each member of the group has been diagnosed with either DM 1 or 2. A member of the group asks, "if we each follow our usual daily diabetic control routine, which diabetic complication is most likely to occur during this athletic event?" the nurse's best answer is which of the following? 1. DKA 2. hypoglycemia 3. HHS 4. impaired glucose tolerance
2
The preferred admin time for recombinant tissue plasminogen activator is within how long of a stroke symptoms onset? 1. 45 minutes 2. 3 hours 3. 6 hours 4. 24 hours
2
The pt arrives in the Ed reporting headache, fever, nausea, and photosensitivity. Which diagnostic test does the nurse anticipate the physician will order to rule out meningitis? 1. x-ray of skull 2. lumbar puncture 3. myelography 4. cerebral angiogram
2
The pt is at risk for increased ICP and is receiving oxygen at 2L NC. the nurse is reviewing the ABG results. Which ABG value is of greatest concern for this pt.? 1. pH = 7.34 2. PaCO2 = 49 3. PaO2 = 95 4. HCO3 = 28
2
What is the duration of the oliguric phase of acute kidney injury? 1. Hours to days 2. Up to 14 days or longer 3. 1-3 weeks 4. several months to one year
2
Which is true regarding the antimuscarinic class of medication that treates MS? 1. it helps the large intestine to absorb water, increase the bulk of stool. 2. it reduces bladder spasms by inhibiting acetylcholine 3. it inhibits transmission of impulses through parasympathetic nerve fibers 4. it mimics the effects of hormones produced in the adrenal glands
2
a client involved in an auto accident has severe spinal cord injuries. If the client is having difficulty with diaphragmatic breathing, which level of the spinal cord is injured? 1. C1 to C4 2. C6 to C7 3. T1 to T12 4. Below L1
2
a client sustained an accident and was brought immediately to the hospital . The imaging results show nearly 1.5 cm deep renal lacerations that do not involve the collecting system. Which grading of renal trauma would be given to the client? 1. Grade 2 2. Grade 3 3. Grade 4 4. Grade 5
2
a nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect? 1. polyuria 2. facial edema 3. smokey brown urine 4. HTN
2
a nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of the condition? 1. tracks an object with eyes 2. sits with pillow props 3. smiles when a parent appears 4. uses a pincer grasp to pick up a toy
2
a nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi? 1. protein in the urine 2. dehydration 3. iron deficiency 4. obesity
2
the nurse is caring for the pt with the risk for impaired swallowing. Which intervention does the nurse employ for this patient? 1. limit the diet to clear liquids 2. give small spoonful of custard 3. give tiny bits of finely cut-up chicken 4. chat with the pt while the pt eats
2
the pt has an infratentorial craniotomy. Which position does the nurse utilize for this pt.? 1. high-fowlers position; turned to the operative side 2. HOB at 30 degrees, turned to the nonoperative side 3. flat in bed, turned tot eh operative side 4. flat in bed, may turn to either side
2
which is associated with decreased mineralocorticoids due to hypopituitarism? 1. hypoglycemia 2. hyponatremia 3. decreased cortisol levels 4. decreased ability to handle stress
2
which statement about the pituitary gland is correct? 1. the main role of the posterior pituitary is to secrete tropic hormones. 2. the posterior pituitary gland stores hormones produced by the hypothalamus 3. the anterior pituitary is connected to the thalamus gland 4. the anterior pituitary releases stored hormones produced by the hypothalamus
2
The pt with Guillain-Barre syndrome desribes a chronologic progression of motor weakness that started int eh legs and then spread to the arms and the upper body. Which typ eof GBS d othese symptoms indicate? 1. pure motor 2.ascending 3. descending
2.
A patient diagnosed with type 2 DM is admitted to the ICU with HHNK. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations 2. Diarrhea and epigastric pain 3. dry mucous membranes 4. ketone breath odor
3
The nurse assesses a client who has a hemisection of the spinal cord resulting from a gunshot injury. The client has lost motor functions, proprioception, and vibration of the injured side. Which kind of incomplete injury of the client can the nurse identify from the scenario? 1. central cord syndrome 2. anterior cord syndrome 3. Brown-Séquard syndrome 4. Posterior cord syndrome
3
The nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? 1. kernig's sign 2. nuchal rigidity 3. Brudzinski's sign 4. bradykinesia
3
The nurses observes the client experiencing a partial seizure Which behavior does the nurse document as automatism 1. unilateral, rhythmic muscle movements 2. rhythmic jerkiness of all extremities 3. repetitive unconscious movements 4. visualization or hallucination
3
Which is a common complication of ALS 1. seizures 2. paralysis 3. pneumonia 4. muscle spasm
3
Which of the following statements best describes Duchenne muscular dystrophy? 1. it has an autosomal dominant inheritance pattern 2. onset occurs in later childhood and adolescence 3. it is characterized by presence of Gower sign, waddling gait, and lordosis 4. disease stabilizes during adolescence, allowing for life expectancy to approximately age 40 years
3
a nurse is assessing a 3-year-old for hemolytic uremic syndrome (HUS). Which assessment finding would be most characteristic of HUS? 1. decreased creatinine 2. elevated pH 3. oliguria 4. decreased RR
3
a nurse is orienting the new licensed nurse in the care of an infant who has meylomeningocele. Which fo the following actions by the new nurse indicates the teaching has been effect? 1. perform range of motion on infant's hips 2. maintains a dry dressing over the sac 3. takes an axillary temperature 4. places the infant in a side-lying position
3
during shift report, the nurse hears that the pt with GBS has a decrease in vital capacity that is less than 2/3 of normal, and there is a progressive inability to clear and cough up secretions. The physician has been notified and is coming to evaluate the pt. What intervention is the nurse prepared to implement for this patient 1. frequent oral suctioning 2. rigorous chest physiotherapy 3. elective intubation 4. elective tracheostomy
3
the nurse in caring for the client with acute kidney injury who has a serum potassium level of 5.5. The nurse administers sodium polystyrene sulfonate to the client. What is the rationale behind this nurses action? 1. to stabilize the myocardial cell membrane 2. to facilitate the elimination of potassium in urine 3. to enhance the total body elimination of potassium 4. to facilitate the intracellular movement of potassium
3
the pt has been diagnosed with subarachnoid hemorrhage. Which drug does the nurse anticipate will be ordered to control cerebral vasospasm? 1. phenytoin 2. dexamethasone 3. nimodipine 4. clopidogrel
3
when planning care for a pt with MS, what is the most appropriate goal for the clinical problem of activity intolerance related to muscle weakness? 1. Pt will maintain muscle strength in his arms and legs 2. Pt can identify three factors that aggravate muscle weakness 3. Pt will participate in daily activities as desired without fatigue 4. Pt is free of trauma related to muscle weakness
3
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include int he plan of care? 1. provide respite services for the parents 2. improve the client's communication skills 3. foster self-care activities 4. modify the environment
4
A nruse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take? 1. apply cold compress to the client's flank area 2. restrict protein intake to 2 servings per day 3. discourage ambulation 4. encourage intake of at least 3 L of fluids per day
4
A nurse in the ED is caring for a client who has DKA and a blood glucose level of 925. Then nurse should anticipate which of the following prescriptions from the provider? 1. glucocorticoid meds 2. dextrose 5% in 0.45% sodium chloride 3. oral hypoglycemia medications 4. 0.9% sodium chloride IV bolus
4
A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client? !. nephrosclerosis 2. uremia 3. divverticulitis 4. cystitis
4
A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? 1. delay in disease progression 2. improved bladder function 3. relief of depression 4. decreased tumor
4
The nurse is assessing the clinical manifestation reports of four clients. Which client is most likely to have renal trauma? 1. edema of lower extremities, abdominal pain 2. nocturia, fever and chills 3. flank mass, hypertension, weight loss 4. hypotension, flank bruising, gross hematuria
4
The nurse is carefully monitoring the pt with a severe case of encephalitis for sign s of increased Intracranial pressure. What vital sign changes are associated with increase ICP? 1. tachycardia and shallow, rapid respirations 2. increased core temperature and bradycardia 3. decreased pulse pressure and tachypnea 4. widened pulse pressure and bradycardia
4
The pt is admitted for a probably diagnosis of GBS, but needs additional diagnostic testing for confirmation. Which test does the nurse anticipate will be ordered for this patient? 1. electroencephalography (EEG) 2. cerebral blood flow (CBF) 3. electrocardiogram (ECG) 4. electromyography (EMG)
4
The pt is treated in the Ed for a status epilepticus and is admitted to the hospital. The physician orders seizures precautions. What equipment does the nurse place in the room prior to the pts arrival 1. cardiac monitor and pule oximeter 2. penlight and a neurological flow sheet 3. padded tongue blades and padding for side rails 4. oxygen and suction equipment
4
What is likely cause of viral meningitis 1. lumbar puncture 2. intraventricular catheter 3. traumatic injury 4. lack of immunization against mumps
4
a nurse is discussing lab values associated with the renal system with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the values? 1. potassium levels are increased in clients who have polyuria 2. specific gravity is decreased in clients how have hypovolemia 3. BUN is decreased in clients who have dehydration 4. creatinine levels are increased in the client who have acute kidney injury
4
a nurse is providing teaching to a client who has nephrotic syndrome. the nurse should recognize that which of the following client statements indicates a need for further teaching? 1. i can expect to have swelling in my face 2. I will lose protein in my urine 3. i should expect my provider to prescribe a kidney biopsy 4. I should increase my sodium intake
4
a nurse plans care for a client with overflow incontinence. Which intervention should the nurse include in this clients plan of care to assist with elimination 1. stroke the medial aspect of the thigh 2. use intermittent 3. provide digital anal stimulation 4. use the Valsalva maneuver
4
nursing student is caring for the patient with partial seizures. Which statement by the student indicates an understanding of partial seizures? 1. "The pt should be placed in a vest when sitting in a chair." 2. "there is no medical treatment for partial seizures" 3. "I should have a padded tongue blade at the bedside." 4. "The pt may repeatedly pick at the linens."
4
the home health-care nurse is caring for an elderly client with Alzheimer's disease (AD). Which intervention should the nurse implement for the client? 1. provide the client with semi-soft diet. 2. Encourage the client to take an afternoon nap. 3. Provide the client with a different schedule every day 4. Speak calmly using positive statements
4
the major goals of therapy for children with cerebral palsy include which of the following? 1. cure underlying defect causing the disorder. 2. reverse degenerative processes that have occurred 3. prevent spread to individuals in close contact with children 4. recognize the disoder early and promote optimum development
4
which electrocardiographic change indicates worsened hyperkalemia in a client with acute kidney failure? 1. flattened T wave 2. widened P wave 3. narrowed QRS complex 4. peaked T wave
4
which intervention should the nurse implement for the client admitted to the ICU with encephalitis? 1. restrict the clients water intake 2. position the client's bed next to window 3. allow the family to visit and talk to the client 4. turn and reposition the client every 2 hours
4
in general, GBS is a chronic condition and the subsequent paralysis is permanent
false
Evidence suggests a relationship between myasthenia gravis and hyperplasia of the thymus gland True or False
True
Myasthenia gravis is characterized by remissions and exacerbations True or False
True
although the onset of myasthenia gravis is usually insidious (slow), some instances of fairly rapid development have been caused by infection, emotional upset, pregnancy or anesthesia True or False
True
the Tensilon test can be used to distinguish between a cholinergic crisis and a Myasthenic crisis True or False
True
the most successful treatment of GBS combines plasmapheresis and immunoglobulin
false
the patient with myasthenia gravis is deficient in the neurotransmitter serotonin True or False
false
GBS is the result of a variety of related immune-mediated pathologic process
true
for a patient with GBS, the nurse assesses the patient's motor function every 2-4 hours as a part of the neurologic assessment
true
risk factors for GBS include an upper respiratory tract infection of GI illness and positive antibodies to cytomegalovirus or ebstein-barr virus
true
