Med Surg Exam 4

The patient had an ischemic stroke 5 hours earlier. What treatment do you anticipate? A. Administer nicardipine (Cardene) for the patient's blood pressure of 200/100 mm Hg. B. Administer systemic thrombolytic tissue plasminogen activator (tPA). C. Make patient NPO. D. Administer acetaminophen (Tylenol) prophylactically.

C About 25% of patients worsen in the first 24 to 48 hours after a stroke. Patients should have nothing by mouth (NPO) until the stroke has stabilized to ensure there is no progression to loss of gag reflex and aspiration. Elevated blood pressure is common immediately after a stroke and may be a protective response to maintain cerebral perfusion. A drug is not used to lower blood pressure unless the systolic pressure is more than 220 mm Hg. Systemic tPA must be administered within 3 to 4.5 hours of stroke onset. The patient's temperature is treated, but not prophylactically.

What does the pathophysiology of Alzheimer's disease (AD) most commonly involve? A. Presence of presenilin-1 and presenilin-2 genes B. Dissolving of plaques in brain tissue C. Changes in brain structure and function D. Residual inflammation from arboviruses

C Characteristic findings of AD are related to changes in the brain's structure and functions: (1) amyloid plaques (more in certain parts of the brain); (2) neurofibrillary tangles (more plentiful than normally seen); and (3) loss of connections between cells and cell death (and atrophy). Three genes are important in the cause of early-onset AD, but only a small percentage of people younger than 60 years develop AD. All individuals develop plaques in their brain tissue as part of aging, but in AD, there are more plaques in certain parts of the brain. Encephalitis is a treatable cause of dementia.

Which sensory-perceptual deficit is associated with a left-brain stroke? A. Overestimation of physical abilities B. Difficulty judging position and distance C. Slow and possibly fearful performance of tasks D. Impulsivity and impatience at performing tasks

C Patients with a left-brain stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-brain stroke.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1. Speaking loudly. 2. Using a picture board. 3. Writing directions so client can read them. 4. Speaking in short sentences.

2. Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.

When communicating with a client who has aphasia, which of the following nursing interventions is not appropriate? 1. Present one thought at a time. 2. Encourage the client not to write messages. 3. Speak with normal volume. 4. Make use of gestures.

2. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to "show me" and should encourage the use of gestures to assist in getting the message across with minimal frustration and exhaustion for the client.

The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions? 1. "I will take Aspirin if I have any discomfort." 2. "I will sleep on the side that I was operated on." 3. "I will wear my eye shield at night and my glasses during the day." 4. "I will not lift anything if it weighs more that 10 pounds."

3. The client is instructed to wear a metal or plastic shield to protect the eye from accidental and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the side of the body on which the operation occurred. The client is not to lift more than 5 pounds.

The patient is admitted with a diagnosis of bacterial meningitis. The patient has a temperature of 101° F and a headache rated as an 8. Which prescription has a priority for you to administer? A. IV cefuroxime (Ceftin) B. Vital signs C. PO acetaminophen (Tylenol) D. Neurologic check

A Bacterial meningitis is a medical emergency, and treating the cause is a priority over treating the symptoms or further assessing effects of the disease process. The antibiotic may be given after cultures are obtained but before the diagnosis is confirmed.

You approach the patient with AD to provide her bath. The patient states, "Go away! I'm not taking a bath." What is your initial response? A. Leave and reapproach in a few minutes. B. Ask the patient why she feels that way. C. Inform the patient that the physician will be notified. D. Obtain additional help and proceed with the bath.

A Behavioral problems occur in about 90% of patients with AD. They can respond to redirection, reapproach, distraction, and reassurance. Persons with AD have limited verbal skills and are not able to respond to "why" questions. You should not threaten with restraints or to call the physician. It is always preferable to try a nonthreatening approach first, especially for something that is not absolutely essential.

Which modifiable risk factors for stroke are most important for you to include when planning a community education program? A. Hypertension B. Hyperlipidemia C. Alcohol consumption D. Oral contraceptive use

A Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated.

Which measure should you prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? A. Vigilant infection control and adherence to standard precautions B. Careful monitoring of neurologic vital signs and frequent reorientation C. Maintenance of a calorie count and hourly assessment of intake and output D. Assessment of blood pressure and monitoring for signs of orthostatic hypotension

A Infection control is a priority in the care of patients with MS since infection is the most common precipitator of an exacerbation of the disease. Decreases in cognitive function are less likely and MS does not typically result in hypotension or fluid volume excess or deficit.

What is a major goal of treatment for the patient with AD? A. To maintain patient safety B. To maintain or increase body weight C. To return to a higher level of self-care D. To enhance functional ability over time

A The overall goals are that the patient with AD will (1) maintain functional ability for as long as possible, (2) be maintained in a safe environment with a minimum of injuries, (3) have personal care needs met, and (4) have dignity maintained. You should emphasize patient safety while planning and providing nursing care.

Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A) Hypertension B) Hyperlipidemia C) Alcohol consumption D) Oral contraceptive use

A) Hypertension Rationale: Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.

Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A) Maintenance of the patient's airway B) Positioning to promote cerebral perfusion C) Control of fluid and electrolyte imbalances D) Administration of tissue plasminogen activator (tPA)

A) Maintenance of the patient's airway Rationale: Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do FIRST? a. Institute seizure precautions b. Assess neurologic status c. Place in respiratory isolation d. Assess vital signs

Answer C. The initial therapeutic management of acute bacterial meningitis includes isolation precautions, initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses should take necessary precautions to protect themselves and others from possible infection.

A male client has just had a cataract operation without a lens implant. In discharge teaching, the nurse will instruct the client's wife to: 1. Feed him soft foods for several days to prevent facial movement 2. Keep the eye dressing on for one week 3. Have her husband remain in bed for 3 days 4. Allow him to walk upstairs only with assistance.

Answer: 4. Without a lens, the eye cannot accommodate. It is difficult to judge distance and climb stairs when the eyes cannot accommodate. Therefore, the client should walk up and down stairs only with assistance.

The early stage of AD is characterized by A. no noticeable change in behavior. B. memory problems and mild confusion. C. increased time spent sleeping or in bed. D. incontinence, agitation, and wandering behavior.

B An initial sign of AD is a subtle deterioration in memory.

You would expect to find which clinical manifestation in a patient admitted with a left-brain stroke? A. Impulsivity B. Impaired speech C. Left-sided neglect D. Short attention span

B Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech and language aphasias, impaired right and left discrimination, and slow and cautious performance. The other options are all manifestations of right-sided brain damage.

For a patient with a suspected stroke, which important piece of information should you obtain? A. Time of the patient's last meal B. Time at which stroke symptoms first appeared C. Patient's hypertension history and management D. Family history of stroke and other cardiovascular diseases

B During initial evaluation, the single most important point in the patient's history is the time of onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with an acute onset of symptoms.

What nursing measure is indicated to reduce the potential for seizures and increased ICP in a patient with bacterial meningitis? A. Administering codeine for relief of head and neck pain B. Controlling fever with prescribed drugs and cooling techniques C. Keeping the room darkened and quiet to minimize environmental stimulation D. Maintaining the patient on strict bed rest with the head of the bed slightly elevated

B Fever must be vigorously managed because it increases cerebral edema and the frequency of seizures. Neurologic damage may result from an extremely high temperature over a prolonged period. Acetaminophen or aspirin may be used to reduce fever; other measures, such as a cooling blanket or sponge baths with tepid water, may be effective in lowering the temperature.

Which measure is most effective in preventing the spread of viral meningitis? A. Have close personnel wear surgical masks. B. Avoid touching respiratory secretions. C. Obtain yearly vaccinations. D. Gargle daily with salt wate

B Viral meningitis is usually acquired through direct contact with respiratory secretions. Bacterial meningitis has respiratory precautions until the cultures are negative, and precautions require a particulate respirator mask rather than surgical mask. There is no yearly vaccination for viral meningitis. The use of Haemophilus influenzae vaccine has decreased the incidence of bacterial meningitis caused by this organism, and the vaccine against Neisseria meningitides provides protection against that organism that causes bacterial meningitis. Gargling with salt water is a helpful home measure, but not touching infectious secretions is more effective.

When providing community health care teaching regarding the early warning signs of AD, which signs would you advise family members to report (select all that apply)? A. Misplacing car keys B. Loses the sense of time C. Difficulty performing familiar tasks D. Problems with performing basic calculations E. Becoming lost in a usually familiar environment

B,C,D,E Difficulty performing familiar tasks, problems with performing basic calculations, and becoming lost in a usually familiar environment are early warning signs of AD. Misplacing car keys is a normal frustrating event for many people.

A 65-year-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is A. searching the Internet for educational videos. B. evaluating the home for environmental safety. C. promoting physical exercise and a well-balanced diet. D. designing an exercise program to strengthen and stretch specific muscles.

C Promotion of physical exercise and a well-balanced diet are major concerns for nursing care for patients with Parkinson's disease.

You are assigned to four patients on the clinical unit. Which patient should you assess first? A. Patient with a skull fracture whose nose is bleeding B. Elderly patient with a stroke who is confused and whose daughter is present C. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0 to 10 scale D. Patient who had a craniotomy for a brain tumor 3 days earlier and has continued emesis

C The patient with meningitis should be seen first. Patients with meningitis must be observed closely for manifestations of increased ICP, which is thought to be a result of swelling around the dura and increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or a change in behavior along with a sudden, severe headache may indicate an acute episode of increased ICP. The postoperative cranial surgery patient should be seen second; although nausea and vomiting are common after cranial surgery and can result in increased ICP. Nausea and vomiting should be treated with antiemetics. The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nosebleed and should be seen third. Confusion after a stroke may be expected; the patient should be safe with a family member present.

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A) Overestimation of physical abilities B) Difficulty judging position and distance C) Slow and possibly fearful performance of tasks D) Impulsivity and impatience at performing tasks

C) Slow and possibly fearful performance of tasks Rationale: Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient's increasing sleep disturbances and inability to solve common problems. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a."Where were you were born?" b."Do have any feelings of sadness?" c."What day of the week is it today?" d."How positive is your self-image?"

Correct Answer: C Rationale: This question tests the patient's orientation to time, which is decreased in early Alzheimer's disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.

The client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching? A. "It is important to post my medicine schedule at home, so my family knows my schedule." B. "I can continue to take over-the-counter drugs." C. "An extra supply of medicine should be kept in my car." D. "Wearing a watch with an alarm will remind me to take my medicine."

Correct answer B Clients with MG should not take any over-the-counter medications without checking with their health care provider.

What is the best patient to assign to a new graduate nurse on her first week of orientation? A. Patient with bacterial meningitis admitted from the emergency department today B. Patient returning from a craniotomy for a pituitary brain tumor C. Patient with head trauma with suspected epidural bleed admitted 3 hours earlier D. Patient with viral meningitis who is being discharged today

D The new nurse should have the patient who is the most stable and has a predictable outcome. That is the patient with the less serious condition of viral meningitis who is being discharged. The other three patients are potentially unstable and need skilled nursing assessments.

Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? A) Present several thoughts at once so that the patient can connect the ideas. B) Ask open-ended questions to provide the patient the opportunity to speak. C) Finish the patient's sentences to minimize frustration associated with slow speech. D) Use simple, short sentences accompanied by visual cues to enhance comprehension.

D) Use simple, short sentences accompanied by visual cues to enhance comprehension. Rationale: When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation.

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a. He didn't arrive within the time frame for that therapy b. Not every is eligible for this drug. Has he had surgery lately? c. You should discuss the treatment of your husband with your doctor d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

D: The medication you are talking about dissolves clots and could cause more bleeding in your husband's head- tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if he or she has further questions.

A client is concerned that he will develop a stroke because his father did at an early age. Which of the following could the nurse instruct this client to modify in order to help reduce this client's risk factors for stroke? a. Keep blood pressure as low as possible. b. Avoid stress. c. Take an aspirin a day. d. Stop smoking. e. Increase consumption of green leafy vegetables. f. Increase physical activity.

d. Stop smoking. f. Increase physical activity. Rationale: This is correct. Physical activity is a modifiable risk factor. Modifiable risk factors for the development of a stroke include control hyper-/hypotension; control diabetes; stop drug use to include smoking, alcohol consumption, and cocaine; increase physical activity; and control cholesterol levels. This is correct. Smoking is a modifiable risk factor. Modifiable risk factors for the development of a stroke include control hyper-/hypotension; control diabetes; stop drug use to include smoking, alcohol consumption, and cocaine; increase physical activity; and control cholesterol levels. This is incorrect. Hypotension can contribute to the development of a stroke. This is incorrect. Avoiding stress is not considered a modifiable risk factor.