NR 464 - Exam 3 (Saunders)

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family? 1. Discouraging the family from touching the client 2. Explaining equipment and procedures on an ongoing basis 3. Ensuring adherence to visiting hours to ensure the client's rest 4. Encouraging the family not to "give in" to their feelings of grief

2. Explaining equipment and procedures on an ongoing basis

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. On the basis of these findings the nurse suspects dysfunction in which area of the brain? 1. Cerebrum 2. Cerebellum 3. Hippocampus 4. Hypothalamus

4. Hypothalamus

A client seen in an ambulatory clinic has a facial rash that is present on both cheeks and across the bridge of the nose. The nurse interprets that this finding is consistent with manifestations of which disorder? 1. Hyperthyroidism 2. Pernicious anemia 3. Cardiopulmonary disorders 4. Systemic lupus erythematosus (SLE)

4. Systemic lupus erythematosus (SLE)

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1. Confusion 2. Bradycardia 3. Sluggish pupils 4. A widened pulse pressure

1. Confusion

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should plan to place the client in which positions? Select all that apply. 1. Head midline 2. Neck in neutral position 3. Flat, with head turned to the side 4. Head of bed elevated 30 to 45 degrees 5. Head of bed elevated with the neck extended

1. Head midline 2. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? 1. The intracranial pressure reading is normal. 2. The intracranial pressure reading is elevated. 3. The intracranial pressure reading is borderline. 4. An intracranial pressure reading of 8 mm Hg is low

1. The intracranial pressure reading is normal.

The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which condition that is a complication of hypothermia blanket use? 1. Frostbite 2. Skin breakdown 3. Arterial insufficiency 4. Venous insufficiency

2. Skin breakdown

A client with human immunodeficiency virus (HIV) infection has a fever, and histoplasmosis is suspected. The nurse should prepare the client for which diagnostic test to confirm the presence of histoplasmosis? 1. Skin biopsy 2. Sputum culture 3. Western blot test 4. Upper gastrointestinal series

2. Sputum culture

A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse should expect to note documentation of which characteristic sign of SLE? 1. Fever 2. Fatigue 3. Skin lesions 4. Elevated red blood cell count

3. Skin lesions The major skin manifestation of SLE is a dry, scaly, raised rash on the face known as the butterfly rash. Fever and fatigue may occur before and during exacerbation, but these signs and symptoms are vague. Anemia is most likely to occur in SLE.

A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to the client? 1. No further diagnostic studies are needed. 2. A Western blot will be done to confirm these findings. 3. The client probably will have a bone marrow biopsy done. 4. A CD4+ cell count will be done to measure T helper lymphocytes.

2. A Western blot will be done to confirm these findings.

A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse interpret this assessment finding? 1. The histoplasmosis is resolving. 2. The client has disseminated histoplasmosis infection. 3. This is a side effect of the medications given to treat AIDS. 4. The client probably has another infection that is developing.

2. The client has disseminated histoplasmosis infection. Histoplasmosis is caused by Histoplasma capsulatum and usually starts as a respiratory infection in the client with AIDS and then becomes a disseminated infection, with enlargement of lymph nodes, spleen, and liver. The client experiences dyspnea, fever, cough, and weight loss. The remaining options are incorrect.

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa, in which position? 1. 15 degrees of Trendelenburg's 2. Side-lying with the head of the bed flat 3. With the head of the bed elevated at least 30 degrees 4. With the head of the bed elevated no more than 10 degrees

3. With the head of the bed elevated at least 30 degrees

A complete blood cell (CBC) count is performed in a client with systemic lupus erythematosus (SLE). The nurse would suspect that which finding will be noted in the client with SLE? 1. Decreased platelets only 2. Increased red blood cell count 3. Increased white blood cell count 4. Decreased number of all cell types

4. Decreased number of all cell types

A rheumatoid factor assay is performed in a client with a suspected diagnosis of rheumatoid arthritis (RA). Which laboratory result should the nurse anticipate? 1. The presence of inflammation 2. The presence of infection in the body 3. The presence of antigens of immunoglobulin A (IgA) 4. The presence of unusual antibodies of the IgG and IgM types

4. The presence of unusual antibodies of the IgG and IgM types

The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? 1. Blood pressure 2. Motor response 3. Pupillary response 4. Level of consciousness

1. Blood pressure

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? 1. Altered breathing pattern 2. Increased likelihood of injury 3. Ineffective oxygen consumption 4. Increased susceptibility to aspiration

1. Altered breathing pattern

A CD4+ lymphocyte count is performed in a client with human immunodeficiency virus (HIV) infection. When providing education about the testing, what should the nurse tell the client? 1. "It establishes the stage of HIV infection." 2. "It confirms the presence of HIV infection." 3. "It identifies the cell-associated proviral DNA." 4. "It determines the presence of HIV antibodies in the bloodstream."

1. "It establishes the stage of HIV infection."

The nurse is positioning a client who has increased intracranial pressure. Which position should the nurse avoid? 1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees

2. Head turned to the side

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

3. Flaccid paralysis Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who has begun to experience multiple opportunistic infections. Which laboratory test would be most helpful in assessing the client's need for reassessment of treatment? 1. Western blot 2. B lymphocyte count 3. CD4+ cell or T lymphocyte count 4. Enzyme-linked immunosorbent assay (ELISA)

3. CD4+ cell or T lymphocyte count The T lymphocyte or CD4+ cell count indicates whether the client is responding to the medication treatment. The count should increase if the client is responding and should decrease if the client's response is poor. The Western blot and ELISA are tests to assist in diagnosing human immunodeficiency virus infection. The B lymphocyte count is not a priority marker to monitor with AIDS clients.

A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine. The nurse should monitor the results of which laboratory blood study for adverse effects of therapy? 1. Creatinine level 2. Potassium concentration 3. Complete blood cell (CBC) count 4. Blood urea nitrogen (BUN) level

3. Complete blood cell (CBC) count Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Common adverse effects of zidovudine are agranulocytopenia and anemia. The nurse should monitor the CBC count for these changes. Creatinine, potassium, and BUN are unrelated to this medication.

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 1. Insert nasal packing. 2. Document the findings. 3. Contact the health care provider (HCP). 4. Monitor the client's blood pressure and check for signs of increased intracranial pressure.

3. Contact the health care provider (HCP). Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP, because this finding requires immediate intervention. The remaining options are inappropriate nursing actions in this situation.

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? 1. Head of bed flat, head and neck midline 2. Head of bed flat, head turned to the nonoperative side 3. Head of bed elevated 30 to 45 degrees, head and neck midline 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side

3. Head of bed elevated 30 to 45 degrees, head and neck midline After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse determines that the client's clinical manifestations are due to what type of physiologic response? 1. Vagal 2. Peripheral nervous system 3. Sympathetic nervous system 4. Parasympathetic nervous system

3. Sympathetic nervous system

The nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? 1. 5 mm Hg 2. 8 mm Hg 3. 14 mm Hg 4. 22 mm Hg

4. 22 mm Hg

The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications? 1. A history of diarrhea 2. A flattened abdomen 3. Hyperactive bowel sounds 4. Hematest-positive nasogastric tube drainage

4. Hematest-positive nasogastric tube drainage

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? 1. Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 2. The client has compulsive habits that should be ignored as long as they are not harmful. 3. The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. 4. Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

4. Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? 1. Unchanged weight 2. Shift intake 950 mL, output 900 mL 3. Blood urea nitrogen (BUN) 10 mg/dL (3.6 mmol/L) 4. Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)

4. Serum osmolality 280 mOsm/kg H2O (280 mmol/kg) After craniotomy the goal is to keep the serum osmolality on the high side of normal to minimize excess body water and control cerebral edema.

The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse should plan to place the client in which position? 1. Prone 2. Supine 3. Side-lying 4. Semi Fowler's

4. Semi Fowler's

The nurse reviews the record of a client with acquired immunodeficiency syndrome (AIDS) and notes that the client has a diagnosis of Candida. When performing history-taking and assessment, which finding should the nurse anticipate? 1. Hyperactive bowel sounds 2. Complaints of watery diarrhea 3. Red lesions on the upper arms 4. Yellowish-white, curdlike patches in the oral cavity

4. Yellowish-white, curdlike patches in the oral cavity

A client with acquired immunodeficiency syndrome (AIDS) is experiencing fatigue. The nurse should plan to teach the client which strategy to conserve energy after discharge from the hospital? 1. Bathe before eating breakfast. 2. Sit for as many activities as possible. 3. Stand in the shower instead of taking a bath. 4. Group all tasks to be performed early in the morning.

2. Sit for as many activities as possible.

A client with acquired immunodeficiency syndrome (AIDS) has a respiratory infection from Pneumocystis jiroveci and has been experiencing difficulty breathing and resultant problems with gas exchange. Which finding indicates that the expected outcome of care has yet to be achieved? 1. The client limits fluid intake. 2. The client has clear breath sounds. 3. The client expectorates secretions easily. 4. The client is free of complaints of shortness of breath.

1. The client limits fluid intake. The status of the client with a problem concerning gas exchange would be evaluated against the standard outcome criteria for a P. jiroveci infection. These would include options 2, 3, and 4 where breath sounds are clear, the nurse notes that secretions are being coughed up effectively, and the client states that breathing is easier. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? 1. The left side of the body 2. The right side of the body 3. Both sides of the body equally 4. Cranial nerves only, such as speech and pupillary response

1. The left side of the body

The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care? 1. The client's fingers and toes are cool to touch. 2. The client's body temperature is 98°F (36.7°C). 3. The client remains in a fetal position when in bed. 4. The client complains of coolness in the hands and feet only.

2. The client's body temperature is 98°F (36.7°C).

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? 1. Return of spinal shock 2. Malignant hypertension 3. Impending brain attack (stroke) 4. Autonomic dysreflexia (hyperreflexia)

4. Autonomic dysreflexia (hyperreflexia)

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

4. Exhaling during repositioning

A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment? 1. Taste 2. Smell 3. Vision 4. Hearing

3. Vision

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply. 1. Keep liquids at the bedside. 2. Place a towel over the pillowcase. 3. Make sure the pillow has a plastic cover. 4. Keep a change of bed linens nearby in case they are needed. 5. Administer an antipyretic after the client has a spike in temperature.

1. Keep liquids at the bedside. 2. Place a towel over the pillowcase. 3. Make sure the pillow has a plastic cover. 4. Keep a change of bed linens nearby in case they are needed. For clients with AIDS who experience night fever and night sweats, the nurse may offer the client an antipyretic of choice before the client goes to sleep rather than waiting until the client spikes a temperature. Keeping a change of bed linens and night clothes nearby for use also is helpful. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if diaphoresis is profuse. The client should have liquids at the bedside to drink.

A CD4 T-cell count is measured in a client newly diagnosed with human immunodeficiency virus (HIV). In planning care, the nurse understands that which is accurate regarding the CD4 T-cell count? Select all that apply. 1. Falls in response to a declining viral load 2. Is a primary marker of immunocompetence 3. Plays a role in the cell-mediated immune response 4. Is a direct measure of the magnitude of HIV replication 5. Guides decision making regarding timing of initiation of treatment

2. Is a primary marker of immunocompetence 3. Plays a role in the cell-mediated immune response 5. Guides decision making regarding timing of initiation of treatment

A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2? 1. It will cause arteriovenous shunting. 2. It will cause vasodilation of blood vessels in the brain. 3. It will cause blood vessels in the circle of Willis to collapse. 4. It will cause hyperresponsiveness of blood vessels in the brain.

2. It will cause vasodilation of blood vessels in the brain.

The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply. 1. Eye opening 2. Reflex response 3. Best verbal response 4. Best motor response 5. Pupil size and reaction

1. Eye opening 3. Best verbal response 4. Best motor response

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. 1. Giving tepid sponge baths 2. Applying a hypothermia blanket 3. Covering the client with blankets 4. Administering acetaminophen per protocol 5. Placing ice packs over the client's abdomen and in the axilla and groin

1. Giving tepid sponge baths 2. Applying a hypothermia blanket 4. Administering acetaminophen per protocol

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1. Head midline 2. Neck in neutral position 3. Head of bed elevated 30 to 45 degrees 4. Head turned to the side when flat in bed 5. Neck and jaw flexed forward when opening the mouth

1. Head midline 2. Neck in neutral position 3. Head of bed elevated 30 to 45 degrees

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA? 1. Anemia 2. Anorexia 3. Amenorrhea 4. Night sweats

2. Anorexia

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? 1. Ask the family to deliver the care. 2. Leave the client alone until ready to participate. 3. Advise the client that rehabilitation progresses more quickly with cooperation. 4. Acknowledge the client's anger and continue to encourage participation in care.

4. Acknowledge the client's anger and continue to encourage participation in care.

The nurse is teaching a client with paraplegia measures to maintain skin integrity. Which instruction will be most helpful to the client? 1. Shift weight every 2 hours while in a wheelchair. 2. Change bed sheets every other week to maintain cleanliness. 3. Place a pillow on the seat of the wheelchair to provide extra comfort. 4. Use a mirror to inspect for redness and skin breakdown twice a week.

1. Shift weight every 2 hours while in a wheelchair.

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1. Elevate the head of the bed. 2. Examine the rectum digitally. 3. Assess the client's blood pressure. 4. Place the client in the prone position.

1. Elevate the head of the bed.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse should recognize that which are early clinical manifestations of this disorder? Select all that apply. 1. Fatigue 2. Anorexia 3. High fever 4. Weight loss 5. Generalized weakness

1. Fatigue 2. Anorexia 5. Generalized weakness Early manifestations of RA include fatigue, anorexia, generalized weakness, low-grade fever, paresthesias. Weight loss is one of the late manifestations.

The nurse works with high-risk clients in an urban outpatient setting. Which groups should be tested for human immunodeficiency virus (HIV)? Select all that apply. 1. Injection drug abusers 2. Prostitutes and their clients 3. People with sexually transmitted infections (STIs) 4. People who have had frequent episodes of pneumonia 5. People who recently received a blood transfusion for a surgical procedure

1. Injection drug abusers 2. Prostitutes and their clients 3. People with sexually transmitted infections (STIs)

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? 1. It is possible the client can hear the family. 2. The family needs immediate crisis intervention. 3. The client might have wanted a visit from the hospital chaplain. 4. The family could benefit from a conference with the health care provider.

1. It is possible the client can hear the family.

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? 1. Sounds will not be heard clearly unless they are loud. 2. Obtain assistance with ambulation if the client is lightheaded. 3. Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed. 4. Use a check-off system for administering anticonvulsant medications to avoid missing doses.

1. Sounds will not be heard clearly unless they are loud.

A client asks the nurse about obtaining a home test kit to test for human immunodeficiency virus (HIV) status. What should the nurse tell the client? 1. Home test kits are not available for testing at this time. 2. Home test kits may not be as reliable as laboratory blood tests. 3. Home test kits are most reliable immediately after a risk event occurs. 4. Home test kits should not be used; rather, it is important to contact the health care provider (HCP) with concerns about the HIV status.

2. Home test kits may not be as reliable as laboratory blood tests.

An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. The client asks the nurse about the purpose of the test. What should the nurse tell the client about the purpose of the test? 1. Determines the presence of antigens 2. Identifies which additional tests need to be performed 3. Confirms the diagnosis of a connective tissue disorder 4. Confirms the presence of inflammation or infection in the body

4. Confirms the presence of inflammation or infection in the body

A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse suspects that which finding will be reported with this blood test? 1. Increased neutrophils 2. Increased red blood cell count 3. Increased white blood cell count 4. Decreased numbers of all cell types

4. Decreased numbers of all cell types In the client with SLE, a complete blood cell count commonly shows pancytopenia, a decrease in all cell types. This probably is caused by a direct attack on all blood cells or bone marrow by immune complexes. The other options are incorrect.

The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction? 1. Temperature 2. Blood pressure 3. Ability to speak 4. Level of consciousness

4. Level of consciousness

A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that the family needs further teaching if they verbalize to call the health care provider (HCP) for which client sign or symptom? 1. Vomiting 2. Minor headache 3. Difficulty speaking 4. Difficulty awakening

2. Minor headache

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week

1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 4. Turning and repositioning the client at least every 2 hours

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? 1. Reduce environmental noise. 2. Allow visitors as desired by the client and family. 3. Awaken the client every 2 to 3 hours to monitor mental status. 4. Cluster nursing activities to reduce the number of interruptions.

1. Reduce environmental noise.

The nurse is assigned to care for a client with human immunodeficiency virus (HIV) infection. The nurse reviews the client's health care record and notes documentation of toxoplasmosis encephalitis. On the basis of this information, the nurse would assess for which manifestation? 1. Lesions on the skin 2. Mental status changes 3. Changes in bowel pattern 4. Lesions on the oral mucosa

2. Mental status changes

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? 1. PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 2. PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 30 to 35 mm Hg (30 to 35 mm Hg) 3. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 4. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)

4. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? 1. Keeping the client on a stretcher 2. Logrolling the client onto a soft mattress 3. Logrolling the client onto a firm mattress 4. Placing the client on a bed that provides spinal immobilization

4. Placing the client on a bed that provides spinal immobilization

A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse should include which measure in the dietary plan? 1. Provide large, nutritious meals. 2. Serve foods while they are hot. 3. Add spices to food for added flavor. 4. Remove dairy products and red meat from the meal.

4. Remove dairy products and red meat from the meal.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action? 1. Wears a turban to cover the incision 2. Indicates that facial puffiness will be a permanent problem 3. Verbalizes that periorbital bruising will disappear over time 4. States an intention to purchase a hairpiece until hair has grown back

2. Indicates that facial puffiness will be a permanent problem

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem? 1. Intracranial pressure changes 2. A long-term sequela of the injury 3. A worsening of the original injury 4. A short-term problem that will resolve in about 1 month

2. A long-term sequela of the injury

The nurse is assessing a client's muscle strength and notes that when asked, the client cannot maintain the hands in a supinated position with the arms extended and eyes closed. How should the nurse correctly document this finding on the medical record? 1. Client is demonstrating ataxia. 2. Client is exhibiting pronator drift. 3. Client appears to have nystagmus. 4. Client examination reveals hyperreflexia.

2. Client is exhibiting pronator drift.

The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation? 1. Fever 2. Cough 3. Dyspnea at rest 4. Dyspnea on exertion

2. Cough Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. The client with P. jiroveci infection usually has a cough as the first sign. The cough begins as nonproductive and then progresses to productive. Later signs and symptoms include fever, dyspnea on exertion, and finally dyspnea at rest.

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1. Clustering nursing activities 2. Hyperoxygenating before suctioning 3. Maintaining 20 degree flexion of the knees 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed (HOB) at 30 degrees elevation

2. Hyperoxygenating before suctioning 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed (HOB) at 30 degrees elevation

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1. Updating the home safety sheet 2. Leaving the client in an unchilled area of the room 3. Noting a bowel movement on the client progress note 4. Recording the amount of urine obtained with catheterization

2. Leaving the client in an unchilled area of the room The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

2. Nail bed pressure

A client with a traumatic brain injury is able, with eyes closed, to identify a set of keys placed in his or her hands. On the basis of this assessment finding, the nurse determines that there is appropriate function of which lobe of the brain? 1. Frontal 2. Parietal 3. Occipital 4. Temporal

2. Parietal

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. 1. Use products that contain alcohol. 2. Position the client on his or her side. 3. Brush the teeth with a small, soft toothbrush. 4. Cleanse the mucous membranes with soft sponges. 5. Use lemon glycerin swabs when performing mouth care.

2. Position the client on his or her side. 3. Brush the teeth with a small, soft toothbrush. 4. Cleanse the mucous membranes with soft sponges.

The home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about home care measures. Which statements by the client indicate the need for further instruction? Select all that apply. 1. "I need to sit whenever possible." 2. "I need to be sure to eat a balanced diet." 3. "I need to take a hot bath every evening." 4. "I need to rest for long periods of time every day." 5. "I should engage in moderate low-impact exercise when I am not tired."

3. "I need to take a hot bath every evening." 4. "I need to rest for long periods of time every day." Hot baths may exacerbate the fatigue. To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit whenever possible, avoid hot baths, engage in moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint stiffness.

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention should the nurse plan to implement? 1. Check cranial nerve functioning. 2. Determine the cause of the accident. 3. Draw blood for arterial blood gas analysis. 4. Perform a pulmonary wedge pressure measurement.

3. Draw blood for arterial blood gas analysis. Assessment should be specific to the area of the brain involved. The respiratory center is located in the brainstem. Assessing the respiratory status is the priority for a client with a brainstem injury. The actions in the remaining options are not priorities, although they may be a component in the assessment process, depending on the injury and client condition.

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration? 1. Using adult diapers 2. Inserting a Foley catheter 3. Establishing a toileting schedule 4. Padding the bed with an absorbent cotton pad

3. Establishing a toileting schedule

The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? 1. Fever, hypotension, and polyuria 2. Hypertension, polyuria, and thirst 3. Fever, hypertension, and graft tenderness 4. Hypotension, graft tenderness, and hypothermia

3. Fever, hypertension, and graft tenderness

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? 1. Notify the health care provider (HCP). 2. Loosen tight clothing on the client. 3. Place the client in a sitting position. 4. Check the urinary catheter tubing for kinks or obstruction.

3. Place the client in a sitting position.

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions noted on the skin

3. Positive punch biopsy of the cutaneous lesions Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

A client is tested for human immunodeficiency virus (HIV) infection with an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. What should the nurse tell the client? 1. HIV infection has been confirmed. 2. The client probably has a gastrointestinal infection. 3. The test will need to be confirmed with a Western blot. 4. A positive test result is normal and does not mean that the client has acquired HIV.

3. The test will need to be confirmed with a Western blot.

A client with acquired immunodeficiency syndrome has been started on therapy with zidovudine. The nurse assesses the complete blood cell (CBC) count, knowing that which is an adverse effect of this medication? 1. Polycythemia 2. Leukocytosis 3. Thrombocytosis 4. Agranulocytopenia

4. Agranulocytopenia

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose.

4. Fluid separates into concentric rings and tests positive for glucose.

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client? 1. Take and record vital signs every 4 to 8 hours. 2. Prophylactically hyperventilate during the first 24 hours. 3. Treat a central fever with the administration of antipyretic medications such as acetaminophen. 4. Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

4. Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE? 1. Ascites 2. Emboli 3. Facial rash 4. Two hemoglobin S genes

3. Facial rash Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. A butterfly rash on the cheeks and bridge of the nose is an essential sign of SLE. Ascites and emboli are found in many conditions but are not associated with SLE. Two hemoglobin S genes are found in sickle cell anemia.

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

1. "I should take hot baths because they are relaxing." To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. Which findings are consistent with acute rejection of the transplanted kidney? Select all that apply. 1. Oliguria 2. Hypotension 3. Fluid retention 4. Temperature of 99.6°F (37.6°C) 5. Serum creatinine of 3.2 mg/dL (282 mcmol/L)

1. Oliguria 3. Fluid retention 5. Serum creatinine of 3.2 mg/dL (282 mcmol/L) Rejection is the most serious complication of transplantation and the leading cause of graft loss. In rejection, a reaction occurs between the tissues of the transplanted kidney and the antibiodies and cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection is the most common type that occurs with kidney transplants and occurs 1 week to any time postoperatively. It occurs over days to weeks. Findings consistent with acute rejection include oliguria or anuria; temperature higher than 100°F (37.8°C); increased blood pressure; enlarged, tender kidney; lethargy; elevated serum creatinine, blood urea nitrogen, and potassium levels; and fluid retention.

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

1. Protecting the client from infection

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? 1. "When did the injury occur?" 2. "Was the client awake and talking right after the injury?" 3. What medications has the client received since the fall?" 4. "What was the client's level of consciousness before the injury?"

2. "Was the client awake and talking right after the injury?"

The nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath sounds. Which judgment should the nurse formulate for the client? 1. Impaired nutritional intake 2. Increased risk for aspiration 3. Increased likelihood for injury 4. Susceptibility to fluid volume deficit

2. Increased risk for aspiration

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? 1. Take the temperature. 2. Listen to breath sounds. 3. Observe for dyskinesias. 4. Assess extremity muscle strength.

2. Listen to breath sounds.

A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply. 1. Fever 2. Seizures 3. Hypoxia 4. Ischemia 5. Hypotension 6. Increased intracranial pressure (ICP)

3. Hypoxia 4. Ischemia 5. Hypotension 6. Increased intracranial pressure (ICP) Secondary brain injury can occur several hours to days after the initial brain injury and is a major concern when managing brain trauma. Nursing management of the client with an acute intracranial problem must include management of secondary injury. Manifestations of secondary injury includes hypoxia, ischemia, hypotension, and increased ICP that follows primary injury. It does not include fever or seizures.

A client reports to the health care clinic for testing for human immunodeficiency virus (HIV) immediately after being exposed to HIV. The test results are negative, and the client expresses relief about not contracted HIV. What should the nurse emphasize when explaining the test results to the client? 1. No further testing is needed. 2. The test should be repeated in 1 month. 3. A negative HIV test result is considered accurate. 4. A negative HIV test result is not considered accurate immediately after exposure.

4. A negative HIV test result is not considered accurate immediately after exposure. A test for HIV should be repeated if results are negative. Seroconversion is the point at which antibodies appear in the blood. The average time for seroconversion is 2 months, with a range of 2 to 10 months. For this reason, a negative HIV test result is not considered accurate immediately after exposure. The remaining options are incorrect.

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis (RA). What result should the nurse anticipate in the presence of this disease? 1. Neutropenia 2. Hyperglycemia 3. Antigens of immunoglobulin A (IgA) 4. Unusual antibodies of the IgG and IgM type

4. Unusual antibodies of the IgG and IgM type Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The test for rheumatoid factor detects the presence of unusual antibodies of the IgG and IgM type, which develop in a number of connective tissue diseases. The other options are incorrect.