NUR 130: Exam Three TB
A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke?
27-year-old heavy cocaine user
After a stroke, a client has ataxia. What intervention is most appropriate to include on the clients plan of care?
Ambulate only with a gait belt
A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis
A 74-year-old man who smokes and has a fractured pelvis
A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.)
A client with a moderate trauma may need hospitalization, a client with a Glascow Coma score of 3 has a severe TBI, the terms mild TBI and concussion have similar meanings
A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching the client? (Select all that apply.)
Acyclovir (Zovirax), Famciclovir (Famvir), Prednisone (Deltasone), Valacyclovir (Valtrex)
A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.)
Admission can overwhelm the coping mechanisms for older clients, client is more susceptible for systemic and wound infections, very few TBI's occur in this age
An older adult client is hospitalized with Guillain-Barr syndrome. The client is given amitriptyline (Elavil). After receiving hand-off report, what actions by the nurse are most important?
Advising the client to have help getting up, Consulting the provider about the drug, Placing the client on safety precautions,
A client is having a temporary tracheostomy placed during surgery for oral cancer. What action by the nurse is best to relieve anxiety?
Agree on a postoperative communication method
The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.)
Alcohol intake, High-fat diet, Obesity, Smoking
A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.)
Alcohol, Caffeine, Carbonated beverages, Vitamin D
A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). What statement should the nurse include while delegating this care?
Allow the client to be as independent as possible with activities
A nursing student studying the neurologic system learns which information? (Select all that apply.)
An aneurysm is a ballooning in a weakened part of an arterial wall, intracerebral hemorrhage is bleeding directly into the brain, subarachnoid hemorrhage is caused by high blood pressure
A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Cutting foods up into small bites, Thickening liquids prior to drinking
A nurse assesses a client with Alzheimers disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete?
Evaluate the client's reaction to the change of the environment
A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Applying a cool washcloth to the head, Assisting the client to a position of comfort, Keeping voices soft and soothing, Maintaining low lighting in the room
The student learning about vision should remember which facts related to the eyes? (Select all that apply.)
Aqueous humor controls intraocular pressure, glaucoma occurs due to increased pressure in the eye, muscles of the iris control light entering the eye, rods work in low light settings
A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best?
Arrange a home safety evaluation
The nurse caring for a client with Guillain-Barr syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.
Ask occupational therapy to help the client with activities of daily living, consult with provider about PT consult, work with speech therapy to design a high protein diet
A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best?
Ask the client to explain his feelings related to this disorder.
A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best?
Ask the pt about fear of falling
A client with a stroke has damage to Brocas area. What intervention to promote communication is best for this client?
Assess if the patient is able to write
An older client is hospitalized with Guillain-Barr syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?
Assess the client's oxygenation saturation
A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best?
Assess the clients gag-reflex
A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the clients care? (Select all that apply.)
Assess tube placement per agency policy, Keep the head of the bed elevated at least 30 degrees, listen to lung sounds at least every 4 hours, run continuous feeds on the feeding pump
A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?
Avoid large crowds and people who are sick
A client had a retinal detachment and has undergone surgical correction. What discharge instruction is most important?
Avoid reading, writing, or close work such as sewing
A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best?
Because eye pressure was too high, the tissue died.
A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Check and document oxygen saturation every 1 to 2 hours, elevate the HOB 45 degrees to prevent aspiration
A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.)
Chocolate, Citrus fruits, Peppermint, Tomato sauce
A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)
Client who exhibits extreme emotional lability, Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38, Client who has a past hospitalization for a suicide attempt, Client who is unable to walk or eat 3 weeks post-stroke
A nurse is caring for four clients. After receiving the hand-off report, which client should the nurse see first?
Client who had a tracheostomy 4 hours ago and needs frequent suctioning
A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first?
Client who had an esophagectomy with a respiratory rate of 32/min
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?
Client who has a temperature of 102 F (38.9 C) - fevers are poor prognosis of brain injury
A nurse is seeing clients in the ophthalmology clinic. Which client should the nurse see first?
Client who has had cataract surgery and has worsening vision
A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should be seen first?
Client with a Glasgow Coma Scale score that was 10 and is now is 8
A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.)
Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches, Client with an aneurysm clip who states that his family is happy there is no chance of recurrence
A nurse studying cancer knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.)
Coal miner, Metal worker, Plumber, Textile worker
The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.)
Colon cancer, Diverticulitis, Inflammatory bowel disease, Peptic ulcer disease
The nurse is aware of the 2014 American Cancer Society Screening Guidelines for colon cancer, which include which testing modalities for people over the age of 50? (Select all that apply.)
Colonoscopy every 10 years, Computed tomography (CT) colonography every 5 years
The nursing student learns that age-related changes affect the eyes and vision. Which changes does this include? (Select all that apply.)
Decreased eye muscle tone, Decrease in general color perception, Increase in point of near vision, Development of arcus senilis
The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.)
Delayed gastric emptying, Eating large meals, Hiatal hernia, Obesity
A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.)
Dilated pupils, Widened pulse pressure, Bradycardia
A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.)
Discharging the client on a statin medication, Providing and charting stroke education, Preventing venous thromboembolism
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask?
Do you live in a crowded residence?
The nurse is working with clients who have esophageal disorders. The nurse should assess the clients for which manifestations? (Select all that apply.)
Dysphagia, Eructation, Halitosis
A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)
Edema Increased capillary permeability, Unequal pulses Increased production of lactic acid, Cyanosis Anaerobic metabolism
A nurse cares for a client with advanced Alzheimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond?
Engage the client in scheduled activities
A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client?
Ensure that the weights remain freely hanging at all times.
An older client has decided to give up driving due to cataracts. What assessment information is most important to collect?
Feelings related to loss of driving
What information does the nurse teach a women's group about osteoporosis?
For 5 years after menopause, you lose 2% of bone mass yearly.
A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.)
Is allergic to acetaminophen (Tylenol), Lives alone and is new in town with no friends, Plans to have a beer and go to bed once home
A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met?
Has clear lung sounds on auscultation
After teaching the wife of a client who has Parkinson's disease, the nurse assesses the wife's understanding. Which statement made by the clients wide indicates she understands the changes accosted with this disease?
He may have trouble chewing so i will offer bite-sized portions
A nurse has delegated applying a warm compress to a clients eye. What actions by the unlicensed assistive personnel (UAP) warrant intervention by the nurse? (Select all that apply.)
Heating the wet washcloth in the microwave, . Holding the cloth on the client using an Ace wrap
A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury?
Hematuria
A client is taking timolol (Timoptic) eyedrops. The nurse assesses the clients pulse at 48 beats/min. What action by the nurse is the priority?
Hold the eyedrops and notify the provider.
A client with Guillain-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
Inadequate airway
A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, Will the medication my mother is taking improve her dementia? How should the nurse respond?
It will not improve dementia but it will help with the emotional response
A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?
Its a good thing I love orange and cherry gelatin - client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood.
A nurse plans care for a client with Parkinson's disease. Which intervention should the nurse include in this client's plan of care?
Keep the HOB 30 or greater
A nurse prepares to discharge a client with Alzheimers disease. Which statement should the nurse include in the discharge teaching for this clients caregiver?
Install deadbolt locks on all outside doors
To promote comfort after a colonoscopy, in what position does the nurse place the client?
Left lateral
The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?
Liver
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer?
Lorazepam (Ativan)
A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered a test on my heart, how should the nurse respond?
Most of these type of blood clots come from the heart
The nurse assesses a clients Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client?
Needs frequent re-orientation
A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority?
Notify the Rapid Response Team
A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority?
Notify the provider immediately.
A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
Notify the provider of the findings immediately
A client who is near blind is admitted to the hospital. What action by the nurse is most important?
Orient the patient to the room using a focal point
A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?
Risk for acquiring an infection - indicates leaking of CSF
A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client?
Performing appropriate hand hygiene
A client has a bone density score of 2.8. What action by the nurse is best?
Planning to teach about bisphosphonates
A phone triage nurse speaks with a client who has an arm cast. The client states, My arm feels really tight and puffy. How should the nurse respond?
Please come to the clinic today to have your arm checked out by the provider
A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client?
Poor prognosis and cognitive function
A student nurse is providing care to an older client with stomatitis and dysphagia. What action by the student nurse requires the registered nurse to intervene?
Preparing to administer a viscous lidocaine gargle
A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The clients respiratory rate is 8 breaths/min. What action by the nurse is best?
Provide physical stimulation
A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client?
Rotate the clients meal tray when the client stops eating.
A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the clients fingers are pale, cool, and slightly swollen. Which action should the nurse take first?
Raise the arm above the level of the heart
A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best?
Remind the client that a small amount of bleeding is possible.
A nurse delegates care for a client with early-stage Alzheimers disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care?
Reorient the client to the day, time and environment each time
A client is admitted with Guillain-Barr syndrome (GBS). What assessment takes priority?
Respiratory system
The nurse learns that the pathophysiology of Guillain-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what?
Slowed nerve impulse transmission
A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the clients score to be 36. How should the nurse plan care for this client?
The client will need near total care
A nurse who is applying eyedrops to a client holds pressure against the corner of the eye nearest the nose after instilling the drops. The client asks what the nurse is doing. What response by the nurse is best?
This avoids systemic absorption
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain?
Time of symptom onset
A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity?
Tonic-clonic seizure
A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to unlicensed assistive personnel (UAP)?
Use a cloth-covered pillow to elevate the legs
A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment does the finding indicate that the priority goal for this client problem has been met?
Weight gain of 3 pounds in 1 month
A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, The cast is loose enough to slide off. How should the nurse respond?
You will need a new cast now that the swelling has decreased
A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority?
call the rapid response team
A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best?
autoimmune problem in which nerves do not cause muscles to contract
A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include? (Select all that apply.)
bone changes lead to potential safety risks, osteoporosis is a universal occurrence, some muscle atrophy occurs with aging
A client had cataract surgery. What instructions should the nurse provide? (Select all that apply.)
call the doctor for increased pain, do not bend over from the waist, do not lift more than 10 lbs, use stool softeners to avoid constipation
A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)
have suction at the bedside, keep bedrails up at all times, ensure the client has IV access
A client is seen in the ophthalmology clinic with bacterial conjunctivitis. Which statements by the client indicate a good understanding of home management of this condition? (Select all that apply.)
i will throw away all my eye make-up when i get home, when the infection if gone i can wear my contacts again
A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.)
strengthening exercises are important, take recommended calcium and Vit D, walk 30 min at least 3x/week
A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment should the nurse wear? (Select all that apply.)
surgical mask, gloves
