NAH Review

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate? Fresh fish Cheddar cheese Cherries Chicken

Cheddar cheese The nurse should eliminate aged cheeses from the diet of a client who is prescribed selegiline. Cheddar cheese contains tyramine, which can cause a hypertensive crisis.

A nurse is preparing a presentation at a community center about systemic lupus erythematosus (SLE). The nurse should plan to include which of the following findings as a manifestation of SLE? Hypothermia Muscle hyperreflexia Weight gain A raised rash

A raised rash A dry, raised rash (butterfly rash) on the face or on sun exposed areas of the body is a manifestation of SLE.

A nurse is planning care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan of care? Provide a high carbohydrate diet. Administer acetaminophen for pain. Encourage eating three large meals daily. Include high protein snacks.

Provide a high carbohydrate diet. A client with hepatitis should have a diet high in carbohydrates due to altered nutrient metabolism.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? Turn the client's head to the side. Check the client's motor strength. Loosen the clothing around the client's waist. Document the time the seizure began.

Turn the client's head to the side. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration.

A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take? Provide warming measures for the client. Hyperextend the client's neck. Flex the client's hip. Adjust the client's head of bed.

Adjust the client's head of bed. The nurse should adjust the client's head of bed to keep CPP greater than 70 mm Hg.

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? Delay in disease progression Improved bladder function Relief of depression Decreased tremors

Decreased tremors Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty walking, and problems with balance and coordination. Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may be helpful in controlling tremors in the early stage of the disease.

A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis? Developing a respiratory infection Taking too much prescribed medication Diet high in protein Not exercising enough

Developing a respiratory infection The most common triggers of myasthenic crises are respiratory infection, not taking, or taking too little, of the prescribed medication, surgery, and high environmental temperatures.

A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse's priority? Elevate the client's feet. Increase the client's IV fluid rate. Initiate a dopamine IV infusion for the client. Administer a unit of packed RBCs.

Increase the client's IV fluid rate. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to increase the client's IV fluid rate. Providing fluid to the client will restore circulating volume and increase blood pressure.

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? Administer diuretics. Restrict the client's intake of fluids. Reduce the client's intake of protein. Administer vitamin K.

Reduce the client's intake of protein. Ammonia is formed in the gastrointestinal tract by the action of bacteria on protein. Limiting dietary protein intake can assist with decreasing the client's ammonia level. Protein is necessary for healing, so strict limitation of dietary protein is not recommended.

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse? Slow the rate to 20 mL/hr. Continue the rate at 125 mL/hr. Slow the rate to 50 mL/hr. Increase the rate to 250 mL/hr.

Slow the rate to 50 mL/hr. The nurse should decrease the rate to 50 mL/hr to minimize cerebral edema and prevent increased intracranial pressure.

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? The client states having a severe headache. The client's bladder becomes distended. The client's blood pressure becomes elevated. The client states having nasal congestion.

The client's bladder becomes distended. Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face.

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? Confusion Weakness Increased intracranial pressure Increased urinary output

Weakness Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory distress or predispose the client to respiratory infections.

A nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. The client states, "I don't need this medication. I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream? Glucose Ammonia Potassium Bicarbonate

Ammonia Lactulose, a disaccharide, is a sugar that works as an osmotic diuretic. It prevents absorption of ammonia in the colon. Accumulation of ammonia in the bloodstream, which occurs in pathologic conditions of the liver, such as cirrhosis, may affect the central nervous system, causing hepatic encephalopathy or coma.

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? Decreased level of consciousness Tachypnea Bilateral weakness of extremities Hypotension

Decreased level of consciousness As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness, decrease. Other manifestations include severe headache, irritability, and pupils that are slow to react or are unreactive to light.

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood? Elevated blood urea nitrogen (BUN) Elevated HbA1c Decreased chloride Decreased bilirubin

Elevated blood urea nitrogen (BUN) As the body digests blood, BUN rises. An elevated BUN is an indication of GI bleeding.

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) Headache Neck pain and stiffness Slurred speech Pupillary changes Disorientation

Headache is correct. A client who has increasing ICP might manifest a headache. Neck pain and stiffness is incorrect. Neck pain and stiffness are not manifestations of increasing ICP. Slurred speech is correct. A client who has increasing ICP might manifest slurred speech. Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes. Disorientation is correct. A client who has increasing ICP might display disorientation or confusion.

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? Transient ischemic attack (TIA) Hemorrhagic stroke Thrombotic stroke Embolic stroke

Hemorrhagic stroke A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including sudden onset of a severe headache, a decrease in the level of consciousness, and seizures. Hemorrhagic strokes occur when bleeding occurs in the brain caused by the rupture of an aneurysm or arteriovenous malformation, hypertension and atherosclerosis, or trauma.

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take? Ambulate the client four times per day. Encourage the client to consume clear liquids. Provide frequent oral and nares care. Keep the client in a supine position.

Provide frequent oral and nares care. A client who has a Sengstaken-Blakemore tube in place is unable to swallow. If the client is alert, the nurse should encourage the client to spit saliva into a tissue or basin. If the client is not alert, gentle suctioning of the oral cavity and nares might be required to remove secretions.

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider? Edematous bruise on forehead Small drops of clear fluid in left ear Pupils are 4 mm and reactive to light Glasgow Coma Scale (GCS) score of 12

Small drops of clear fluid in left ear Clear fluid in the ear canal might be cerebrospinal fluid (CSF) and indicates a basilar skull fracture. CSF drainage is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents. This finding should be reported to the provider.

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client? Moist skin Spider angiomas Tarry stools Blood in the urine

Spider angiomas Spider angiomas are lesions with a red center and numerous extensions that spread out like a spider web. This is an expected finding for a client who has cirrhosis.

A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer? Vitamin K Heparin Warfarin Ferrous sulfate

Vitamin K A prothrombin time of 30 seconds indicates the clotting time is prolonged and bleeding could occur. Vitamin K injection increases the synthesis of prothrombin by the liver; therefore, the nurse should plan to administer vitamin k.

A nurse is caring for a client who has cirrhosis and a new prescription for lactulose. Which of the following manifestations indicates an adverse effect of the medication? Dry mouth Vomiting Headache Peripheral edema

Vomiting The nurse will monitor for vomiting as an adverse effect of lactulose.

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting? "My wife tries to get me to go to the grocery store, but I don't like to go out much." "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." "My greatest pleasure each day is having a few beers every day." "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."

"I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." The client is adapting to the physical condition and displays goal setting.

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? "Wear an eye patch on the right eye at all times." "Plan to relax in a hot tub spa each day." "Engage in a vigorous exercise program." "Implement a schedule to include periods of rest."

"Implement a schedule to include periods of rest." The nurse should assist the client in developing a schedule that includes periods of exercise followed by periods of rest to maintain muscle strength and coordination.

A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C? A client who eats raw shellfish A client who has multiple tattoos A client who works in a child care center A client who has recently traveled to a underdeveloped country

A client who has multiple tattoos Hepatitis C is transmitted via blood-to-blood contact. The nurse should recognize that improperly maintained tattoo equipment may aid in transmission and could increase the client's risk for contracting hepatitis C.

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? Ability to achieve independent transfer from bed to wheelchair Independent control of bowel and bladder function Use of a wheelchair with a chin or mouth stick Ability to self-feed with the use of adaptive equipment

Ability to self-feed with the use of adaptive equipment A client who has a spinal cord transection at the level of the fifth cervical vertebrae should have full neck, partial shoulder, back, biceps, and gross elbow movements. A realistic rehabilitation goal for the client is the ability to feed himself with the use of adaptive equipment.

A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis? Alcohol Caffeine Cocaine Inhalants

Alcohol Chronic alcohol use disorder is one of the primary causes of cirrhosis of the liver.

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next? Complete a vascular assessment. Administer an antipyretic. Decrease environmental stimuli. Assess the cranial nerves.

Assess the cranial nerves. The greatest risk to the client is from increased intracranial pressure (ICP) which may lead to herniation of the brain and death. The nurse should perform neurological assessments including evaluation of the cranial nerves at least every 4 hr. Early neurological changes to be monitoring for include a decrease in the level of consciousness, the development of Cushing's triad (severe hypertension, widened pulse pressure, and bradycardia), and changes in pupillary reaction.

A nurse is caring for a client who has myasthenia gravis. The nurse should recognize that this disease is caused by which of the following types of hypersensitivities? Immediate Cytotoxic Immune complex-mediated Delayed

Cytotoxic The nurse should recognize myasthenia gravis as a cytotoxic hypersensitivity. Other examples of this hypersensitivity include autoimmune hemolytic anemia and Goodpasture's syndrome.

A nurse is reviewing the laboratory results of a client who has liver failure with ascites and is receiving spironolactone. Which of the following findings should the nurse expect? Decreased sodium level Decreased phosphate level Decreased potassium level Decreased chloride level

Decreased sodium level The nurse should expect a decreased sodium level. Spironolactone is a potassium-sparing diuretic that inhibits the action of aldosterone, resulting in an increased excretion of sodium.

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE? Sunlight Pregnancy Infection Exercise

Exercise Deconditioning and muscle atrophy occurs as a result of lack of mobility. The nurse should encourage client to engage in conditioning exercises alternated with periods of rest.

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? Instruct the client to cough and deep breathe. Place the client in a supine position. Place a warming blanket on the client. Use log rolling to reposition the client.

Use log rolling to reposition the client. Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned.

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching? "Insert a padded tongue blade into the client's mouth." "Restrain the client." "Place the client on his back." "Move objects away from the client."

"Move objects away from the client." The nurse should instruct the family to move objects away from the client to reduce the risk of injury to the client.

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? "Turn the screws on the device once each day." "The purpose of this device is to immobilize the cervical spine." "Apply talcum powder under the vest to limit friction." "The purpose of this device is to allow for neck movement during the healing process."

"The purpose of this device is to immobilize the cervical spine." A client who has an injury to the cervical spine can have a halo fixation device to provide immobilization of the head and neck for a period of 8 to 12 weeks.

A nurse is performing discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include? "Avoid using moisturizing lotions on your skin." "Wash your hair with a mild protein shampoo." "Apply powder liberally to sensitive skin areas." "Use a sun-blocking agent with a sun protection factor of at least 15."

"Wash your hair with a mild protein shampoo." Clients who have SLE are prone to hair loss and should use a mild protein shampoo and avoid treatments that can damage the hair and scalp, such as dyes and permanents.

A nurse is providing discharge teaching to a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include? Avoid using moisturizing lotions on the skin. Wash the hair with a mild protein shampoo. Apply powder liberally to sensitive skin areas. Use a sun-blocking agent with a sun protection factor of at least 15.

Wash the hair with a mild protein shampoo. Clients who have SLE are prone to hair loss. They should use a mild protein shampoo and avoid treatments that can damage the hair and scalp, such as dyes and permanents.

A nurse is teaching a client who taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects? Excess salivation Difficulty voiding Diarrhea Slow pulse

Difficulty voiding The nurse should instruct the client to report difficulty voiding, which may indicate urinary retention, as an adverse effect of benztropine. Benztropine is an anticholinergic medication that helps decrease the rigidity and tremors of Parkinson's disease.

A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following interventions should the nurse take? Elevate the head of the bed to 30°. Notify the provider for drainage greater than 80 mL/8hr. Place the client in a flat, lateral position. Provide passive range-of-motion exercises to the neck.

Elevate the head of the bed to 30°. The client who has surgery to treat a supratentorial brain tumor is at risk for increased intracranial pressure (ICP). Elevation of the head of the bed to 30° assists in promoting venous and CNS fluid drainage from the head to prevent increased ICP.

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? Cleanse the perineum from back to front. Obtain a prescription for an indwelling urinary catheter. Encourage fluid intake at and between meals. Offer the client the bedpan every 2 hr.

Encourage fluid intake at and between meals. Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is reduced, even for a client who has a spinal cord injury.

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test? A pill-rolling tremor appears. Muscle contractions become progressively stronger. Electrical charge in a muscle increases in intensity. Muscle strength shows no change.

Muscle contractions become progressively stronger. A positive Tensilon test is indicated by a 4 to 5 min period of improved muscle tone and strength.

A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? Avoid eating at fast food restaurants. Avoid serving raw foods. Practice effective hand hygiene. Wear barrier protection during vaginal intercourse.

Practice effective hand hygiene. Effective hand hygiene—along with immunization, sewer sanitation, and a safe water supply—are the most effective strategies for preventing the transmission of hepatitis A.

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take? Prepare the client for mechanical ventilation. Administer an anticholinesterase medication. Instruct the client to perform the pursed lip breathing. Prepare to administer a vasoconstrictor.

Prepare the client for mechanical ventilation. The client who is experiencing a myasthenic crisis is at risk for loss of adequate respiratory function. The nurse should closely monitor the client's respiratory status and prepare for possible mechanical ventilation.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? Wrinkles in the skin Constipation Iritis Facial rash

Facial rash SLE affects the skin. A facial "butterfly" rash that is dry, scaly, red, and raised is a manifestation of SLE.

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? Administer a nitrate antihypertensive. Assess the client for bladder distention. Place the client in a high-Fowler's position. Obtain the client's heart rate.

Place the client in a high-Fowler's position. The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse's initial action should be to place the client in a high-Fowler's position to assist in providing immediate reduction in blood pressure and intracranial pressure.

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client? "Do have a history of chronic alcohol abuse?" "Have you had a recent influenza infection?" "Have traveled overseas recently?" "Are you taking a multivitamin?"

"Have you had a recent influenza infection?" The nurse should ask the client about a recent Haemophilus influenzae infection. The cause of GBS is unknown, but it usually follows a viral infection.

A nurse is preparing to administer clonazepam 1.5 mg PO in 3 equally divided doses every 8 hr for a client who has seizures. The amount available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

1 tablet per dose

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? A change in the Glasgow Coma Scale score from 13 to 11 Diplopia A drop in heart rate from 76 to 70/min Ataxia

A change in the Glasgow Coma Scale score from 13 to 11 In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider.

A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.) Administer furosemide. Administer warfarin. Implement a low-sodium diet. Measure the client's abdominal girth. Encourage weight lifting during physical therapy.

Administer furosemide is correct. The nurse should administer furosemide to the client to reduce fluid accumulation in the abdomen. Administer warfarin is incorrect. The nurse should avoid administering warfarin to the client due to possible destruction of platelets caused by splenomegaly, which can result in spontaneous bleeding.Propranolol is prescribed instead to discourage bleeding. Implement a low-sodium diet is correct. The nurse should implement a low-sodium diet to control fluid accumulation in the abdomen. Measure the client's abdominal girth is correct. The nurse should measure the client's abdominal girth. Daily weights are an even more reliable indicator of fluid accumulation. Encourage weight lifting during physical therapy is incorrect. The nurse should understand weight lifting can cause bleeding.

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication? Have the client empty his bladder. Put up the side rails on the client's bed. Ask the client to take a few sips of water. Place the client in low Fowler's position.

Ask the client to take a few sips of water. Clients who have myasthenia gravis, an autoimmune disorder, have weakness of the muscles of the face and throat, which increases the risk for aspiration. The nurse should check the client's ability to swallow before administering oral medication.

A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? Apply downward pressure while the client shrugs his shoulders upward. Apply resistance while the client lifts his legs from the bed. Ask the client to grasp an object and form a fist. Apply resistance while the client flexes his arms.

Apply downward pressure while the client shrugs his shoulders upward. This assessment monitors the motor function of C4 to C5.

A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation? Avoid covering sores with bandages. Avoid handwashing after eating. Avoid foods prepared with tap water. Avoid eating meat.

Avoid foods prepared with tap water. To decrease the risk for acquiring viral hepatitis, clients should prepare foods with purified water.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? Pruritus Hypertension Bradykinesia Xerostomia

Bradykinesia The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.) Confusion Bradycardia Hypotension Nonreactive dilated pupils Slurred speech

Confusion is incorrect. A change in the level of consciousness is an early sign of neurologic status. This is often manifested as restlessness, irritability, and confusion. Bradycardia is correct. Bradycardia is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have tachycardia. Hypotension is incorrect. Severe hypertension is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have hypotension. Nonreactive dilated pupils is correct. Increased intracranial pressure can lead to nonreactive dilated pupils or constricted nonreactive pupils. Slurred speech is incorrect. Slowed speech can be an early sign of increased intracranial pressure. Late manifestations include stupor, progressing to coma, and abnormal motor responses, including decorticate and decerebrate posturing.

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care? Decrease the client's fluid intake. Increase the client's saturated fat intake. Increase the client's sodium intake. Decrease the client's carbohydrate intake.

Decrease the client's fluid intake. The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client's risk for increased fluid retention.

A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan? Administer antibiotics. Provide a diet high in fat. Restrict fluids. Encourage short periods of ambulation.

Encourage short periods of ambulation. The nurse should encourage a client who has hepatitis B to alternate between activity and rest.

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? Inform the client that privileges are related to participation in therapy. Limit visiting hours until the client begins to participate in therapy. Allow the client to control the timing and frequency of the therapy. Establish a plan of care with the client that sets attainable goals.

Establish a plan of care with the client that sets attainable goals. The nurse should develop a plan of care for this client with mutually set goals. This action invests the client in the rehabilitation process, which encourages feelings of ownership for it, and sees the goals as more attainable.

A nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. When delivering the client's lunch tray, which of the following items should the nurse identify as contraindicated for the client? Baked potato Stewed tomatoes Ham sandwich Milkshake

Ham sandwich Ham is high in sodium and can increase fluid retention, leading to edema. Clients who have cirrhosis are prone to edema as the osmotic pressures change due to a decrease in plasma albumin and are placed on low-sodium diets.

A nurse is caring for a client with who has hepatitis A. The client asks the nurse how he might have contracted the virus. Which of the following is a question the nurse should ask the client? "Have you eaten any fresh water fish lately?" "Have you received a blood transfusion recently?" "Have you been to a third world country in the past?" "Do you take any recreational drugs?"

Have you been to a third world country in the past?" The nurse should understand Hepatitis A is particularly prevalent in third world countries and may be the cause of contracting the virus from contaminated food or water.

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.) Hypotension Polyuria Hyperthermia Absence of bowel sounds Weakened gag reflex

Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal cord. Polyuria is incorrect. The nurse should check the client for bladder distention and inability to urinate due to ineffective function of the bladder muscles. Hyperthermia is incorrect. The nurse should monitor the client for hypothermia caused by a lack of lack of sympathetic input. Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client to develop a paralytic ileus. Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.) Loosen restrictive clothing. Insert a bite stick into the client's mouth. Place the client into a supine position. Place a pillow under the client's head. Apply restraints.

Loosen restrictive clothing is correct. Loosening clothing, such as a belt or collar, aids in respiratory and abdominal expansion. The client should not be restrained. Insert a bite stick into the client's mouth is incorrect. A bite stick or padded tongue blade can cause an obstruction in the client's airway or further injury if teeth are broken as a result of the jaw clamping down on the bite stick. Place the client into a supine position is incorrect. If it is possible to do without causing injury to the client, the nurse should assist the client who is having a seizure into a lateral position. This position assists with the drainage of saliva and mucus, preventing aspiration, and allows the tongue to fall forward, preventing airway obstruction. Place a pillow under the client's head is correct. The nurse should place a pillow or rolled blanket under the client's head to protect the head from injury. Apply restraints is incorrect. The nurse should not restrict movement of a client who is having a seizure. Instead, the nurse should guide the client's movements to prevent injury and, if possible, assist the client into a lateral position.

A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform? Deflate the balloons for 5 min every 2 hr to prevent tissue necrosis. Maintain constant observation while the balloons are inflated. Suction the tube every 2 hr and as needed to maintain patency. Keep the head of the bed flat at all times to prevent the development of shock.

Maintain constant observation while the balloons are inflated. A Sengstaken-Blakemore tube is used to stop or slow bleeding from the esophagus and stomach. When the balloons are inflated, they put pressure on the areas that are hemorrhaging to tamponade the bleeding. While the balloons are inflated, the client must be observed constantly because displacement can cause airway obstruction.

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? Albumin 25% Dextran 70 Hydroxyethyl glucose Mannitol 25%

Mannitol 25% The nurse should plan to administer mannitol 25%, an osmotic diuretic that lowers intracranial pressure by promoting diuresis.

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.) Massage over erythematous bony prominences. Implement turning schedule every 4 hr. Use pillows to keep heels off the bed surface. Keep the client's skin dry with powder. Minimize skin exposure to moisture.

Massage over erythematous bony prominences is incorrect. The nurse should avoid massaging bony prominences, since it may cause further skin break down. Implement turning schedule every 4 hr is incorrect. The nurse should implement a 2 hr turning schedule to prevent skin breakdown. Use pillows to keep heels off the bed surface is correct. The nurse should keep the heels off the bed to prevent skin breakdown on the client's heels. Keep the client's skin dry with powder is incorrect. The nurse should apply lotion and avoid applying powder to the skin, which may cause skin breakdown. Minimize skin exposure to moisture is correct. The nurse should minimize skin exposure to moisture to prevent skin breakdown.

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? Insert a padded tongue blade into the client's mouth. Place a pillow under the client's head. Gently restrain the client's extremities. Apply a face mask for oxygen administration.

Place a pillow under the client's head. The nurse should place a small pillow or other soft padding under the client's head to protect the client from injury during the seizure, and turn his head to the side to keep the airway clear.

A nurse is teaching a client about causes of biliary cirrhosis. Which of the following information should the nurse include in the teaching? Excessive alcohol consumption Hepatitis C Hepatotoxic medications Obstruction of the bile duct

Obstruction of the bile duct Prolonged obstruction of the common bile duct is the most common cause of biliary cirrhosis.

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care? Obtain IV access. Keep the lights on when the client is sleeping. Place the client's bed in the high position. Keep a padded tongue blade available at the client's bedside.

Obtain IV access. The nurse should obtain IV access as a precaution so the client can receive IV medications in the event of a seizure.

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? Paresthesia Hemiplegia Quadriplegia Paraplegia

Paraplegia Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect? Petechiae Hypertension Osteoarthritis Peripheral ulcers

Petechiae A manifestation of advanced cirrhosis is petechiae due to impaired coagulation from a dysfunctional liver.

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? Check the client for a fecal impaction. Examine the client for areas of skin breakdown. Check the client's bladder for distention. Place the client in a sitting position.

Place the client in a sitting position. The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertension.

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? Insert a tongue blade in the client's mouth. Place the client on his side. Hold the client's arms and legs from moving. Place the client back in bed.

Place the client on his side. The nurse should place the client on his side. This position drops the tongue to the side of the client's mouth and prevents the client's airway from being obstructed.

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.) Provide a suction setup at the bedside. Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside. Furnish restraints at the bedside.

Provide a suction setup at the bedside is correct. The nurse should provide a suction setup at the bedside to provide oral suctioning as needed following the seizure to prevent aspiration. Elevate the side rails near the head when the client is in bed is correct. The nurse should raise the side rails near the head of the bed to help keep the client in the bed. The nurse should check the facility policy for specific guidelines because raising all side rails can be considered a restraint. Elevate the rails of the bed to prevent a fall during a seizure. Place the bed in the lowest position is correct. The nurse should place the bed in the lowest position to prevent injury if a fall should occur during a seizure. Keep an oxygen setup at the bedside is correct. The nurse should monitor the client's oxygen saturation during a seizure and provide supplemental oxygen as prescribed. Furnish restraints at the bedside is incorrect. The nurse should not plan to restrain a client during a seizure, as this can cause harm to the client's muscles and limbs.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? Provide client supervision. Limit client physical activity. Speak loudly to the client. Leave the television on continuously.

Provide client supervision. Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment.

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected? Pushes the painful stimulus away Extends her body toward the painful stimulus Shows no reaction to the painful stimulus Flexes the upper and extends the lower extremities in response to the painful stimulus

Pushes the painful stimulus away Pushing away a painful stimulus is an expected response.

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan? Apply restraints. Administer opioids. Darken the room. Reduce stimuli.

Reduce stimuli. The nurse should reduce stimuli by decreasing the number of visitors, speaking calmly, and creating a quiet environment.

A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching? You may donate blood 6 months after completing the medication regimen. Consume a high-protein diet. Rest frequently throughout the day. Take acetaminophen every 4 hr, as needed, for discomfort

Rest frequently throughout the day. Limiting activity is usually recommended until the symptoms of hepatitis have subsided. The nurse should recommend the client rest frequently throughout the day to reduce the metabolic demands upon the liver and decrease energy demands.

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? Tachycardia Amnesia Hypotension Restlessness

Restlessness Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement? Droplet Contact Airborne Standard

Standard Hepatitis C is a blood-borne pathogen that is commonly spread by needle stick injury, sharing of IV drug paraphernalia and sexual contact. The nurse should implement standard precautions when in contact with blood, body fluids (except sweat), broken skin, and mucous membranes. The nurse should wear additional personal protective equipment if there is possible blood contact or a risk for splashes or sprays of blood or body fluids.

A nurse is planning care for a client who is postoperative following a liver transplant. and weighs 65 kg. Which of the following actions should the nurse plan to take? Keep the client NPO for the first week postoperative. Limit caloric content once the client resumes eating. Stress the importance of safe food-handling practices. Decrease foods high in carbohydrates once the client resumes eating.

Stress the importance of safe food-handling practices. The nurse should stress the importance of safe food-handling practices to avoid foodborne illness due to the immunosuppressant medications the client is taking.

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? Perform passive range of motion on each extremity. Monitor the client's electrolyte levels. Suction saliva from the client's mouth. Record the client's intake and output.

Suction saliva from the client's mouth. The unconscious client is unable to independently maintain a clear airway and is at risk for ineffective airway clearance. According to the safety and risk reduction priority setting framework, maintaining the client's airway, breathing, and circulation is the highest priority.

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? The client can follow simple motor commands. The client is unable to make vocal sound. The client is unconscious. The client opens his eyes when spoken to.

The client opens his eyes when spoken to. A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.