S4 Unit 3 questions 4

The nurse is assessing a client with numerous areas of bruising. Which question does the nurse ask to determine the cause of this finding? a. "Do you take aspirin?" b. "How often do you exercise?" c. "Are you a vegetarian?" d. "How often do you take Tylenol?"

a

The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client? a. Impaired proprioception b. Aphasia c. Agraphia d. Impaired olfaction

a A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness. The client may present with impaired proprioception and may be disoriented as to time and place. The right cerebral hemisphere does not control speech, smell, or the client's ability to write

The nurse is caring for a client who is disoriented as the result of a stroke. Which action does the nurse implement to help orient this client? a. Ask the family to bring in pictures familiar to the client. b. Turn on the television to a 24-hour news station. c. Maintain a calm and quite environment by minimizing visitors. d. Provide auditory and visual stimulation simultaneously.

a For the client with disorientation, the nurse can request that the family bring in pictures or objects that are familiar to the client. The nurse explains what the object or picture represents in simple terms. These stimuli can be presented several times daily. Visitors can also be familiar stimuli to reorient the client. Too much stimuli and constant stimuli can lead to further confusion.

When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes, a. hypertension, and bradycardia. b. hypertension, and tachycardia. c. hypotension, and bradycardia. d. hypotension, and tachycardia.

a Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushing's triad). It is bradycardia, not tachycardia, which is the component of this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad.

The nurse notes that the left arm of a client who has experienced a brain attack is in a contracted, fixed position. Which complication of this position does the nurse monitor for in this client? a. Shoulder subluxation b. Flaccid hemiparesis c. Pathologic fracture d. Neglect syndrome

a Hypertonia causing contracture or flaccidity can predispose the client to subluxation of the shoulder. Contractures are stiff and immobile—not flaccid. Contractures are not caused by fractures or neglect syndrome.

The nurse is preparing to administer prescribed mannitol (Osmitrol) to a client with a severe head injury. Which precaution does the nurse take before administering this medication? a. Draw up the medication using a filtered needle. b. Have injectable naloxone (Narcan) prepared and ready at the bedside. c. Prepare to hyperventilate the client before drug administration. d. Discontinue a barbiturate-induced coma before drug administration.

a Mannitol (Osmitrol) must be drawn up using a filtered needle to eliminate microscopic crystals. Narcan does not reverse the effects of mannitol. Hyperventilation does not affect administration of this drug, and clients can be given mannitol while in a barbiturate-induced coma.

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min d. A decrease in the client's weight by 6 kg

a Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure.

A client has experienced a stroke resulting in damage to Wernicke's area. Which clinical manifestation does the nurse monitor for? a. Inability to comprehend spoken words b. Communication with rote speech only c. Slurred speech d. Inability to make sounds

a The client with damage to Wernicke's area cannot understand spoken or written words. If the client speaks, the language is meaningless, with the client using made-up words. Damage to Wernicke's area does not cause slurred speech, nor will the client communicate with habitual speech only.

A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, "I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone!" Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the client's refusal, and call the health care provider. d. Contact the provider to request an extra dose of the client's diuretic.

a The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.

A client with aphasia presents to the emergency department with a suspected brain attack. Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic stroke? a. Two episodes of speech difficulties in the last month b. Sudden loss of motor coordination c. A grand mal seizure 2 months ago d. Chest pain and nuchal rigidity

a Thrombotic stroke is characterized by a gradual onset of symptoms that often are preceded by transient ischemic attacks (TIAs), causing a focal neurologic dysfunction. Two episodes of speech difficulties would correlate with TIAs. The other manifestations are not related to a thrombotic stroke.

A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.) a. "How frequently do you drink alcohol?" b. "Have you ever had sex with a man?" c. "Do you have a family history of cancer?" d. "Have you ever worked as a plumber?" e. "Were you previously incarcerated?"

abe When assessing a client with suspected cirrhosis, the nurse should ask about alcohol consumption, including amount and frequency; sexual history and orientation (specifically men having sex with men); illicit drug use; history of tattoos; and history of military service, incarceration, or work as a firefighter, police officer, or health care provider. A family history of cancer and work as a plumber do not put the client at risk for cirrhosis.

After shunt procedure, the nurse would monitor the patient's neurologic status by using the a. electroencephalogram. b. GCS. c. National Institutes of Health Stroke Scale. d. Monro-Kellie doctrine.

b

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily.

b A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful

The nurse assesses periorbital edema and ecchymosis around both eyes of a client who is 6 hours postoperative for craniotomy. Which intervention does the nurse implement for this client? a. Position the client with the head of the bed flat. b. Apply an ice pack to the affected area. c. Assess arterial blood pressure. d. Notify the health care provider.

b Periorbital edema and ecchymosis are expected after a craniotomy. The nurse should attempt to increase the client's comfort by reducing the swelling with application of ice. The provider does not need to be notified. Lowering the head of the bed and assessing blood pressure will not decrease inflammation

A client who had a brain attack was admitted to the intensive care unit yesterday. The nurse observes that the client is becoming lethargic and is unable to articulate words when speaking. What does the nurse do next? a. Check the client's blood pressure and apical heart rate. b. Elevate the back rest to 30 degrees and notify the health care provider. c. Place the client in a supine position with a flat back rest, and observe. d. Assess the client's white blood cell count and differential.

b The client is experiencing signs of increased intracranial pressure (ICP). Raising the head of the bed would help decrease ICP. The health care provider should then be notified immediately so that other interventions to reduce ICP can be instituted. Assessing vital signs and white blood cell count is not the priority at this time.

An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a "steering wheel mark" across the client's chest. Which action should the nurse take? a. Ask the client where in the car he or she was sitting during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.

b The liver is often injured by a steering wheel in a motor vehicle crash. Because the client's chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the client's position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. The client does not need to be in reverse Trendelenburg position

The nurse is caring for a client who is immobile from a recent stroke. Which intervention does the nurse implement to prevent complications in this client? a. Position the client with the unaffected side down. b. Apply sequential compression stockings. c. Instruct the client to turn the head from side to side. d. Teach the client to touch and use both sides of the body.

b To avoid complications of immobility, such as deep vein thrombosis, the nurse applies sequential compression stockings or pneumatic compression boots. Efforts are made to mobilize the client as much as possible, and the client should be repositioned frequently. The other interventions will not prevent complications of immobility.

A nurse obtains a client's health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? a. "I drink two glasses of red wine each week." b. "I take a lot of Tylenol for my arthritis pain." c. "I have a cousin who died of liver cancer." d. "I got a hepatitis vaccine before traveling."

b can cause liver damage

An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations

bd Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion

A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse monitor for in this client? a. Repeated syncope b. New-onset confusion c. Spontaneous ecchymosis d. Abdominal distention

c

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver? a. A 22-year-old with a history of blunt liver trauma b. A 48-year-old with a history of diabetes mellitus c. A 66-year-old who has a history of cirrhosis d. An 82-year-old who has chronic malnutrition

c

The nurse is planning the discharge of a client who has sustained a moderate head injury and is experiencing personality and behavior changes. The client's wife states, "I am concerned about how different he is. What can I do to help with the transition back to our home?" How does the nurse respond? a. "Be firm and let him know when his behavior is unacceptable." b. "Minimizing the number of visitors will help stabilize his personality." c. "Developing a routine will help provide him with a structured environment." d. "He will return to his normal emotional functioning in 6 to 12 months."

c

The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications? a. Administer prescribed analgesics to promote pain relief. b. Cluster nursing procedures together to avoid fatiguing the client. c. Monitor neurologic and vital signs closely to identify early changes in status. d. Position with the head of the bed flat to enhance cerebral perfusion.

c Early detection of neurologic, blood pressure, and heart rhythm changes offers an opportunity to intervene in a timely fashion. Evidence is not yet sufficient to recommend a specific back rest elevation after stroke. Analgesics are often held during the first 72 hours to ensure that the client's neurologic status is not altered by pain medications. Preventing fatigue is not a priority in the first 72 hours.

The nurse observes yellow-tinged sclera in a client with dark skin. Based on this assessment finding, what does the nurse do next? a. Assess the client's pulses. b. Examine the soles of the client's feet. c. Inspect the client's hard palate. d. Auscultate the client's lung sounds.

c Jaundice can best be observed in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Because sclera may have subconjunctival fat deposits that show a yellow hue, and because foot calluses may appear yellow, neither of these areas should be used to assess for jaundice. The client's pulse and lung sounds have no correlation with an assessment of jaundice.

The nurse is performing an admission assessment on a 46-year-old client, who states, "I have been drinking a 12-pack of beer every day for the past 20 years." Which laboratory abnormality does the nurse correlate with this history? a. Decreased white blood cell (WBC) count b. Decreased bleeding time c. Elevated prothrombin time (PT) d. Elevated red blood cell (RBC) count

c The liver is the site for production of prothrombin and most of the blood-clotting factors. If the liver is damaged because of chronic alcoholism, it is unable to produce these clotting factors. Therefore, the PT could become elevated, which would reflect deficiency of some clotting factors.

A client who has a severe head injury is placed in a drug-induced coma. The client's husband states, "I do not understand. Why are you putting her into a coma?" How does the nurse respond? a. "These drugs will prevent her from experiencing pain when positioning or suctioning is required." b. "This medication will help her remain cooperative and calm during the painful treatments." c. "This medication will decrease the activity of her brain so that additional damage does not occur." d. "This medication will prevent her from having a seizure and will reduce the need for monitoring intracranial pressure."

c When intracranial pressure cannot be controlled by other means, clients may be placed in a barbiturate coma to decrease cerebral metabolic demands, decrease formation of vasogenic edema, and produce a more uniform blood supply to the brain. The other responses do not correctly explain the reason for a medication-induced coma. Pain medication should be administered when the client is comatose.

The nurse is assessing a client with liver failure. Which assessment is the highest priority for this client? a. Auscultation for bowel sounds b. Assessing for deep vein thrombosis c. Monitoring of blood pressure hourly d. Assessing for signs of bleeding

d All these options are important in assessment of the client, but the most important action is assessment for signs of bleeding. The liver is the site of production of prothrombin and most of the blood-clotting factors. Clients with liver failure run a high risk of having problems with bleeding

The nurse is caring for an 80-year-old client who presented to the emergency department in a coma. Which question does the nurse ask the client's family to help determine whether the coma is related to a brain attack? a. "How many hours does your mother usually sleep at night?" b. "Did your mother complain recently of weakness in her lower extremities?" c. "Is any history of seizures known among your mother's immediate family?" d. "Does your mother drink any alcohol or take any medications?"

d Conditions such as drug or alcohol intoxication, as well as hypoxemia and metabolic disturbances, can cause profound changes in level of consciousness (LOC) when accompanied by a brain attack. Alcohol abuse and medication toxicity can be especially problematic in older adults. The other manifestations are related to a stroke but would not increase the client's risk of coma

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Assess the client for airway patency.

d Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.

A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a. Nausea and vomiting b. Frontal headache c. Vertigo and syncope d. Mid-sternal chest pain

d Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea and vomiting, headache, and vertigo and syncope are not side effects of vasopressin.

A client with a head injury is being given midazolam (Versed) while on mechanical ventilation. Which action does the nurse implement for this client? a. Monitor for seizures. b. Assess for urinary output. c. Provide a clear liquid diet. d. Administer an analgesic.

d Midazolam (Versed) is a benzodiazepine agent and has no analgesic effect. It should be given with pain medication. This medication does not increase the risk of seizures and does not decrease urinary output. Clients should not be fed when being mechanically ventilated.