ATI EXIT EXAM MED SURG II
A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? A. "I should restrict rapid movements and avoid bending from the waist for several weeks." B. "I should wait until the day after surgery to wash my hair." C. "I will remove the dressing behind my ear in 7 days." D. "My hearing should be back to normal right after my surgery."
A. "I should restrict rapid movements and avoid bending from the waist for several weeks." Rationale: Rapid movements and bending from the waist should be avoided for 3 weeks following ear surgery
A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? A. "I should wash my hands after blowing my nose to prevent spreading the virus." B. "I need to avoid drinking fluids if I develop symptoms." C. "I need a flu shot every 2 years because of the different flue strains." D. "I should cover my mouth with my hand when I sneeze."
A. "I should wash my hands after blowing my nose to prevent spreading the virus." Rationale: Hand hygiene decreases the risk of the client spreading influenza viruses
A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? (Select all that apply). A. "I think I might be pregnant." B. "I take warfarin." C. "I take antihypertensive medication." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning."
A. "I think I might be pregnant." B. "I take warfarin." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning." Rationale: (A) The nurse should report the client's statement of possible pregnancy to the provider because the contrast dye can place the fetus at risk. (B) The nurse should report that the client is taking warfarin to the provider due to the potential for bleeding following angiography (D) The nurse should report a clients report of allergy to shrimp, which is a shellfish, to the provider due to a potential allergic reaction to the contrast dye (E) The nurse should report a client's intake of food to the provider since the client should remain NPO for 4 to 6 hr. prior to the procedure.
A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? (Select all that apply.) A. "It is given to reduce swelling of the brain." B. "You will need to monitor for low blood sugar." C. "You may notice weight gain." D. "Tumor growth will be delayed." E. "it can cause you to retain fluids."
A. "It is given to reduce swelling of the brain." C. "You may notice weight gain." E. "it can cause you to retain fluids." Rationale: (A) Dexamethasone is a common steroid prescribed to reduce cerebral edema (C) Weight gain is an adverse effect of dexamethasone (E) Fluid retention is an adverse effect of dexamethasone.
A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? A. "There are portable oxygen delivery systems that you can take with you." B. "When you go out, you can remove the oxygen and then reapply it when you get home." C. "You probably will not be able to go out as much as you used to." D. "Home health services will come to you so you will not need to get out."
A. "There are portable oxygen delivery systems that you can take with you." Rationale: The nurse should inform the client that there are portable oxygen systems that he can use to leave the house. This should alleviate the client's anxiety.
A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (Select all that apply). A. Areas of paresthesia B. Involuntary eye movements C. Alopecia D. Increased salivation E. Ataxia
A. Areas of paresthesia B. Involuntary eye movements E. Ataxia Rationale: (A) Areas of loss of skin sensation are a finding in a client who has MS. (B). Nystagmus is a finding in a client who has MS. (E) Ataxia occurs in the client who has MS as muscle weakness develops and there is loss of coordination
A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. Avoid overwhelming fatigue B. Remove caffeinated products from the diet. C. Limit looking at flashing lights. D. Perform aerobic exercise E. Limit episodes of hypoventilation F. Use of aerosol hairspray is recommended.
A. Avoid overwhelming fatigue B. Remove caffeinated products from the diet. C. Limit looking at flashing lights. Rationale: (A) The nurse should instruct the client to avoid overwhelming fatigue, which can trigger a seizure by stimulating abnormal electrical neuron activity (B) The nurse should instruct the client to remove caffeinated products from the diet, which can trigger a seizure by stimulating abnormal electrical neuron activity (C) the nurse should instruct the client to refrain from looking at flashing lights, which can trigger a seizure by stimulating abnormal electrical neuro activity
A nurse is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply). A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 5 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis
A. Client who has dysphagia B. Client who has AIDS E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis Rationale: (A) The client who has difficulty swallowing is at increased risk for pneumonia due to aspiration (B) The client who has AIDS is immunocompromised, which increases the risk of opportunistic infections, such as pneumonia (E) Mechanical ventilation is invasive and increases the risk of pneumonia (F) A client who has myasthenia gravis has a generalized weakness and can have difficulty clearing airway secretions, which increases the risk of pneumonia
A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of he following types of bladder management methods? A. Condom catheter B. Intermittment urinary catheterization C. Crede's method D. Indwelling urinary catheter
A. Condom catheter Rationale: The nurse should implement the noninvasive use of a condom catheter, because of the bladder will empty on its own due to the client having an upper motor neuron injury, which is manifested by a spastic bladder.
A nurse is completing an assessment for a client who has increased intracranial pressure (ICP). Which of the following are expected findings? (Select all that apply.) A. Disoriented to time and place B. Restlessness and irritability C. Uequal pupils D. ICP 15 mm Hg E. Headache
A. Disoriented to time and place B. Restlessness and irritability C. Unequal pupils E. Headache Rationale: (A) Changes in the level of consciousness are an early indicator of increased ICP (B) increased ICP can cause behavior changes, such as restlessness and irritability (C) Unequal pupils indicate pressure on the oculomotor nerve secondary to increased ICP (E) A headache is a manifestation of increased ICP.
A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? (Select all that apply.) A. Enlarged adenoids B. Report of recent colds C. Client prescription for daily furosemide D. Light reflex visible on otoscopic exam in the affected ear E. Ear pain relieved by meclizine
A. Enlarged adenoids B. Report of recent colds E. Ear pain relieved by meclizine Rationale: (A) Enlarged tonsils and adenoids are a finding associated with a middle ear infection (B) Frequent colds are findings associated with a middle ear infection (E) Meclizine is prescribed to relieve vertigo for inner ear disorders but does not relieve the pain of a middle ear infection
A nurse is caring for client who has Alzheimer's disease. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurse's response? (Select all that apply). A. Exposure to metal waste products B. Long-term estrogen therapy C. Sustained use of Vitamine E D. Previous head injury E. History of herpes infection
A. Exposure to metal waste products D. Previous head injury E. History of herpes infection Rationale: (A) Exposure to metal and toxic waste is a risk factor for Alzheimer's disease (D) A previous head injury is a risk factor for Alzheimer's disease (E) A history of herpes infection is a risk factor for Alzheimer's disease.
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side-lying position. B. Document the duration of the seizure. C. Reorient the client to the environment. D. Provide client hygiene.
A. Keep the client in a side-lying position. Rationale: The greatest risk to the client is aspiration during the postictal phase. Therefore the priority intervention is to keep the client in a side-lying position so secretions can drain from the mouth keeping the airway patent.
A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply). A. Have suction equipment available for use B. Feed the client thickened liquids C. Place food on the unaffected side of the client's mouth. D. Assign an assistive personnel to feed the client slowly E. Teach the client to swallow with her neck flexed.
A. Have suction equipment available for use B. Feed the client thickened liquids C. Place food on the unaffected side of the client's mouth. E. Teach the client to swallow with her neck flexed. Rationale: (A) Suction equipment should be available in case of choking and aspiration (B) The client should be given liquids that are thicker than water to prevent aspiration (C) Placing food on the unaffected side of the client's mouth will allow her to have better control of the food and reduce the risk of aspiration (E) The client should be taught to flex her neck, tucking the chin down and under to close the epiglottis during swallowing
A nurse in the critical care unit is completing an admission assessment of a client who has an gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (select all that apply). A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension
A. Headache B. Dilated pupils D. Decorticate posturing Rationale: (A) Headache is a finding associated with increased ICP (B) Dilated pupils is a finding associated with increased ICP (D) Decorticate or decerebrate posturing is a finding associated with increased ICP.
A nurse is preparing to administer a dose of a new prescription of prednisone to client who has COPD. The nurse should monitor for which of the following advise affects of this medication? (Select all that apply). A. Hypokalemia B. Tachycardia C. Fluid retention D. Nausea E. Black, tarry stools
A. Hypokalemia C. Fluid retention E. Black, tarry stools Rationale: (A). The nurse should observe for hypokalemia. There is an adverse effect of prednisone (C) the nurse should observe for fluid retention. This is an adverse effect of prednisone (E) The nurse should monitor for black, tarry stools. This is an adverse effect of prednisone.
A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions shoud the nurse plan to take? (Select all that apply). A. Implement seizure precautions. B. Perform neurological checks four times a day. C. Administer morphine for the report of neck and generalized pain. D. Turn off room rights and television E. Monitor for impaired extraocular movements. F. Encourage the client to cough frequently.
A. Implement seizure precautions. D. Turn off room rights and television E. Monitor for impaired extraocular movements. Rationale: (A) the client is at risk for seizures due to possible increased ICP. Therefore, the nurse should implement seizure precautions to reduce the client's risk of injury. (D) the nurse should turn off room lights and the television because they can increase neuron stimulation and cause a seizure when a client is at risk for increased ICP (E) The nurse should monitor for impaired extraocular movements because this finding can indicate increased ICP.
A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply). A. Impulse control difficulty B. Left hemiplegia C. Loss of depth perception D. Aphasia E. Lack of situational awareness
A. Impulse control difficulty B. Left hemiplegia C. Loss of depth perception E. Lack of situational awareness Rationale: (A) A client who has experienced a right-hemispheric stroke will exhibit impulse control difficulty such as the urgency to use the restroom (B) a client who has experienced a right-hemispheric stroke will exhibit left-sided hemiplegia (C) a client who has experienced a right-hemispheric stroke will experience a loss in-depth perception (E) A client who has experienced a right-hemispheric stroke will demonstrate a lack of awareness of surroundings
A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? A. Increase intake of deep yellow and orange vegetables B. Administer eye drops twice daily C. Avoid bending at the waist D. Wear an eye patch at night
A. Increase intake of deep yellow and orange vegetables Rationale: The nurse should instruct the client to increase dietary intake of carotenoids and antioxidants to slow the progression of the macular degeneration.
A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively? (Select all tht apply.) A. Increased intracranial pressure B. Hemorrhagic shock C. Hydrocephalus D. Hypoglycemia E. Seizures
A. Increased intracranial pressure C. Hydrocephalus E. Seizures Rationale: (A) A client who has had a craniotomy should be monitored postoperatively for increased ICP (C) following a craniotomy, the client should be monitored for the development of hydrocephalus (E) seizures is a postoperative complication that should be monitored following a craniotomy
A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement
A. Keep neck stabilized. Rationale: The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out.
A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and id not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? A. Obtain baseline vital signs and oxygen saturation B. Obtain a sputum culture C. Obtain a complete history from the client D. Provide a pneumococcal vaccine
A. Obtain baseline vital signs and oxygen saturation Rationale: The first action the nurse should take using the nursing process is to assess the client, which is essential in planning client-centered care
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (Select all that apply). A. Oxygen equipment B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit
A. Oxygen equipment C. Pulse oximeter D. Sterile dressing Rationale: (A). Oxygen equipment is necessary to have in the client's room if the client becomes short of breath following the procedure (C). Pulse oximetry is necessary to monitor oxygen saturation level during the procedure (D) A sterile dressing is necessary to apply to the puncture site following the procedure
A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply). A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum
A. Persistent cough C. Fatigue D. Night sweats E. Purulent sputum Rationale: (A) The nurse should include in the teaching that a persistent cough is a manifestation of tuberculosis (C) The nurse should include in the teaching that fatigue is a manifestation of tuberculosis (D) The nurse should include in the teaching that night sweats in a manifestation of tuberculosis (E) The nurse should include in the teaching that purulent sputum is a manifestation of tuberculosis
A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (Select all that apply). A. Place cilent in supine position. B. Flex client's hip and knee. C. Place hands behind the client's neck. D. Bend client's head toward chest. E. Straighten the client's flexed leg at the knee.
A. Place cilent in supine position. C. Place hands behind the client's neck. D. Bend client's head toward chest. Rationale: (A) The nurse should place the client in supine position when assessing for Brudzinski's sign (C) The nurse should place her hands behind the client's neck when assessing for Brudzinski's sign, in order to flex the client's neck (D) the nurse should bend the client's head toward the chest when assessing for Brudzinski's sign.
A nurse is caring for client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table B. Explain the procedure C. Obtain ABGs D. Administer benzocaine spray
A. Position the client in an upright position, leaning over the bedside table Rationale: Positioning the client in an upright position and bent over the bedside table widens the intercostal space for the provider to access the pleural fluid
A nurse is assessing the pain level of a client who came to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following components of a pain assessment? A. Presence of associated manifestations. B. Location of the pain C. Pain quality D. Aggravating and relieving factors
A. Presence of associated manifestations. Rationale: Nausea and vomiting are common manifestations clients have when they are in pain
A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair.
A. Prevention of further damage to the spinal cord Rationale: The greatest risk to the client during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention the nurse should take is to prevent further damage to the spinal cord by the administration of corticosteroids, minimizing the movement of the client. until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.
A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply). A. Provide privacy B. Ease the client to the floor if standing C. Move furniture away from the client D. Loosen the client's clothing E. Protect the client's head with padding. F. Restrain the client.
A. Provide privacy B. Ease the client to the floor if standing C. Move furniture away from the client D. Loosen the client's clothing E. Protect the client's head with padding. Rationale: (A) The nurse should implement privacy to minimize the client's embarrassment. (B) the nurse should ease the client to the floor to prevent falling and injury (C) The nurse should move the furniture away from the client to prevent injury (D) The nurse should loosen the client's clothing to minimize restriction of movement (E) The nurse should protect the client's head in her lap or using a pillow or blanket under the head during a seizure
A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (Select all that apply). A. Reduce exposure to bright lighting B. Move head slowly when changing positions C. Do not eat fruit high in potassium D. Plan evenly spaced daily fluid intake E. Avoid fluids containing caffeine.
A. Reduce exposure to bright lighting B. Move head slowly when changing positions D. Plan evenly spaced daily fluid intake E. Avoid fluids containing caffeine. Rationale: (A) Remaining in a darkened, quiet environment can reduce vertigo, particularly when it is severe (B) Moving slowly when standing or changing positions can reduce vertigo (D) Fluid intake should be planned so that it is evenly spaced throughout the day to prevent excess fluid accumulation in the semicircular canals (E) the client should avoid fluids containing caffeine or alcohol to minimize vertigo.
A nurse is making a home visit to a client who has AD. The client's partner states that the client is often disoriented to time and place is unsteady on his feet, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? (Select all that apply.) A. Remove floor rugs. B. Have door locks that can be easily opened. C. Provide increased lighting in stairwells D. Install handrails in the bathroom. E. Place the mattress on the floor.
A. Remove floor rugs. C. Provide increased lighting in stairwells D. Install handrails in the bathroom. E. Place the mattress on the floor. Rationale: (A) Removing floor rugs can decrease the risk of falling (C) Good lighting can decrease the risk for falling in dark areas such as stairways (D) installing handrails in the bathroom can be useful for the client to hold on to when his gait is unsteady (E) By placing the client's mattress on the floor, the risk of falling or tripping is decreased.
A nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include in the teaching? A. Rise slowly when standing B. Expect urine to become dark-colored C. Avoid foods containing tyramine D. Report any skin discoloration.
A. Rise slowly when standing Rationale: Orthostatic hypotension is a common adverse effect of bromocriptine, a dopamine receptor agonist. Therefore, rising slowly when standing up will decrease the risk of dizziness and lightheadedness.
A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply) A. Speak to the client at a slower rate B. Assist the client to use flashcards with pictures C. Speak to the client in a loud voice D. Complete sentences that the client cannot finish E. Given instructions one step at a time.
A. Speak to the client at a slower rate B. Assist the client to use flashcards with pictures E. Given instructions one step at a time. Rationale: (A) Clients who have global aphasia have difficulty with speaking and understanding speech. One strategy that can enhance client understanding is speaking to the client at a slower rate (B) One strategy that can enhance understanding is the use of alternative forms of communication, such as flashcards with pictures or a computer (E) One strategy that can enhance understanding is giving instructions one step at a time.
A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (select all that apply). A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site
A.. Dyspnea C. Fever D. Hypotension Rationale: (A). Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. The nurse should notify the provider immediately (C) Fever can indicate an infection. The nurse should notify the provider immediately (D) Hypotension can indicate intrathoracic bleeding. The nurse should notify the provider immediately
A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? A. "This medication can decrease my immune response." B. "I take this medication to prevent asthma attacks." C. "I need to take this medication with food." D. "This medication has a slow onset to treat my symptoms."
B. "I take this medication to prevent asthma attacks." Rationale: A bronchodilator can prevent asthma attacks from occurring
A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: ionized 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? (Select all that apply). A. "I can substitute one medication for another if I run out because they all fight infection." B. "I will wash my hands each time I cough." C. I will wear a mask when I am in a public area." D. "I am glad I don't have to have any more sputum specimens." E. "I don't need to worry where I go once I start taking my medications."
B. "I will wash my hands each time I cough." C. I will wear a mask when I am in a public area." Rationale: (B) The client should wash her hands each time she coughs to prevent spreading the infection. (C) The client should wear a mask while in public areas to prevent spreading the infection. The client has active TB, which is transmitted through the airborne route
A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements bu the newly licensed nurse indicates an understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows present pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client."
B. "It allows present pressure delivered during spontaneous ventilation." Rationale: PSV Allows preset pressure delivered during spontaneous ventilation to decrease the work of breathing.
A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure." B. "Try to stay away most of the night prior to the procedure." C. "The procedure will take approximately 15 minutes." D. "You will need to lie flat for 4 hours after the procedure."
B. "Try to stay away most of the night prior to the procedure." Rationale: The nurse should teach the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity.
A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? A. "You will need to continue to take the multi medication regimen for 4 months." B. "You will need to provide sputum samples every 4 weeks sputum samples every 4 weeks to monitor the effectiveness of the medication." C. "You will need to remain hospitalized for treatment." D. "You will need to wear a mask at all times."
B. "You will need to provide sputum samples every 4 weeks sputum samples every 4 weeks to monitor the effectiveness of the medication." Rationale: The client who has tuberculosis needs to provide sputum samples ever 2 to 4 weeks to monitor the effectiveness of the medication
A nurse is caring for a client who is postprocedure following a lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply). A. Use the Glasgow Coma Scale when assessing the client. B. Assist the client to a supine position. C. Administer an opioid medication. D. Encourage the client to increase fluid intake. E. Instruct the client to perform deep breathing and coughing exercises.
B. Assist the client to a supine position. C. Administer an opioid medication. D. Encourage the client to increase fluid intake. Rationale: (B) The nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture (C) The nurse should administer an opioid medication for a client's report of headache pain. (D) The nurse should encourage increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture
A nurse in a provider's office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? (Select all that apply.) A. Pain is bilateral across the posterior occipital area. B. Client experiences altered sleep-wake cycle C. Headaches occurs at approximately the same time of the day. D. Client describes headache pain as dull and throbbing E. Nasal congestion and drainage occur
B. Client experiences altered sleep-wake cycle C. Headaches occurs at approximately the same time of the day. E. Nasal congestion and drainage occur Rationale: (B) Cluster headaches can be due to a lack of continuity in the sleep-wake cycle (C) Cluster headaches occur at about the same time of day for 4 to 12 weeks. (E) A client can have a runny nose and nasal congestion with a cluster headache
A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply). A. Suction the endotracheal tube frequently B. Decrease the noise level in the client's room C. Elevate the client's head on two pillows D. Administer a stool softener E. Keep the client well hydrated
B. Decrease the noise level in the client's room D. Administer a stool softener Rationale: (B) Decreasing the noise level and restricting the number of people in the client's room can help prevent increases in ICP (D) Administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increased ICP.
A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8
B. E3 + V4 + M4 = 11 Rationale: The client's score is calculated correctly, indicating moderate head injury. E3 represents opening eyes secondary to voice stimulation, V4 represents the verbal conversation that is incoherent and disoriented and M4 represents motor response as general withdrawal to pain.
A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? A. Gender B. Environmental allergies C. Alcohol use D. Race
B. Environmental allergies Rationale: Environmental allergies are a risk factor associated with asthma. A client who has environmental allergies typically has other allergic problems, such as rhinitis or a skin rash
A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (Select all that apply). A. Gender B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus
B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus Rationale: (B) Genetic predisposition is a risk factor associated with glaucoma (C) Hypertension is a risk factor associated with glaucoma. (D) Age is a risk factor associated with glaucoma. (E) Diabetes mellitus is a risk factor associated with glaucoma
A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply.) A. SaO2 95% B. Wheezing C. Retraction of sternal muscles D. Pink mucous membranes E. Premature ventricular complexes (PVSc)
B. Wheezing C. Retraction of sternal muscles E. Premature ventricular complexes (PVSc) Rationale: (B) Wheezing is a manifestation indicating the client's respiratory status is declining (C) Retraction of sternal muscles is manifestation that the client's respiratory status is declining (E) PVCs are a manifestation that the client's respiratory status is declining
A nurse is caring for a client who has increased ICP and a new. prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria
B. Hyponatremia Rationale: Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia.
A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics B. Implement droplets precautions. C. Initiate IV access D. Decrease bright lights.
B. Implement droplets precautions. Rationale: When using the urgent vs. nonurgent approach to care, the nurse determines the priority action is to initiate droplet precautions when meningitis is suspected to prevent spread of the disease to others.
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension
B. Infection Rationale: The nurse should monitor a client who has a ventriculostomy for infection, which is a complication. The nurse should use strict asepsis to avoid this life-threatening condition, which can result in meningitis.
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids
B. Loss of cognitive function Rationale: Loss of cognitive function is a manifestation associated with MS.
A nurse is caring for a client who has just undergone a crainiotomy for a supratentorial tumor. Which of the following postoperative prescriptions should the nurse clarify with the provider? A. Dexamethasone 30 mg IV bolus BID B. Morphine sulfate 2 mg IV bolus PRN every 2 hr for pain C. Ondansetron 4 mg IV bolus PRN every 4 to 6 hr for nausea D. Pheytoin 100 mg IV bolus TID
B. Morphine sulfate 2 mg IV bolus PRN every 2 hr for pain Rationale: Narcotic analgesics should be avoided postoperatively due to their CNS depressant effects
A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? A. Cataracts B. Open-angle glaucoma C. Macular degeneration D. Angle-closure glaucoma
B. Open-angle glaucoma Rationale: This is a manifestation of open-angle glaucoma. A gradual loss of peripheral vision is a manifestation associated with this diagnosis
A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply). A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure
B. Pale skin E. Elevated blood pressure Rationale: (B) Pale skin is an early manifestation of hypoxemia (E) Elevated blood pressure is an early manifestation of hypoxemia
A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? (Select all that apply). A. Decreased vision B. Pill-rolling tremor of the fingers C. Shuffling gait D. Drooling E. Bilateral ankle edema F. Lack of facial expression
B. Pill-rolling tremor of the fingers C. Shuffling gait D. Drooling F. Lack of facial expression Rationale: (B) The client who has PD can manifest pill-rolling tremors of the fingers due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult (C) The client who has PD can manifest shuffling gait because of overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult (D) The client who has PD can manifest drooling because of overstimulation of the basal ganglia by acetylcholine, making the controlled movement of swallowing secretions difficult (F) The client who has PD can manifest a lack of facial expression due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body B. Place the bedside table on the right side of the bed. C. Orient the client to the food on her plate using the clock method D. Place the wheelchair on the client's left side.
B. Place the bedside table on the right side of the bed. Rationale: The client is unable to visualize to the left midline of her body. Placing the bedside table on the right side of the client's bed will permit the visualization of items on the table.
A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe? A. Keep the call light near the client. B. Place the client in a room close to the nurses' station. C. Encourage the client to ask for assistance. D. Remind the client to walk with someone for support
B. Place the client in a room close to the nurses' station. Rationale: Using the safety and risk reduction priority-setting framework, placing the client in close proximity to the nurses' station for close observation is the first action the nurse should take
A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply). A. Monitor for bradycardia B. Provide an emesis basin at the bedside C. Administer antipyretic medication D. Perform a skin assessment E. Keep the head of bed flat.
B. Provide an emesis basin at the bedside C. Administer antipyretic medication D. Perform a skin assessment Rationale: (B) The nurse should provide an emesis basin at the bedside because the client who has meningitis can have nausea and vomiting (C) The nurse should plan to administer antipyretic medication for rever to a client who has meningitis (D) The nurse should perform a skin assessment to determine whether the client has a red macular rash associated with meningococcal meningitis.
A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which actions should the nurse include in the plan of care? (Select all that apply). A. Provide three large balanced meals daily. B. Record diet and fluid intake daily C. Document weight every other week D. Place the client in Fowler's position to eat. E. Offer nutritional supplements between meals.
B. Record diet and fluid intake daily E. Offer nutritional supplements between meals. Rationale: (B) The nurse should record the client's diet and fluid intake daily to assess for dietary needs and to maintain adequate nutrition and hydration. (E) The nurse should offer nutritional supplements between meals to maintain the client's weight
A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCO2, 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
B. Respiratory alkalosis Rationale: A client who is experiencing respiratory alkalosis will have an increased pH and a decreased PaCO2. Possible cause of respiratory alkalosis includes hyperventilation, fever, and respiratory infections.
A nurse is a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods? A. Bakes salmon B. Salted cashews C. Frozen strawberries D. Fresh asparagus
B. Salted cashews Rationale: Nuts contain tyramine, which can trigger migraine headaches
A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? A. Notify the provider B. Sit the client upright in bed C. Check the urinary catheter for blockage D. Administer antihypertensive medication
B. Sit the client upright in bed Rationale: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated blood pressure caused by autonomic dysreflexia. The first action the nurse should take is to elevate the head of the bed until the client is in an upright position, which should lower the blood pressure secondary to postural hypotension.
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increases the effort of the client's respiratory muscles should the nurse include in the plan of care? (Select all that apply). A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation
B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation Rationale: (B) Synchronized intermittent mandatory ventilation requires that the client generate force to take spontaneous breaths (C) Continuous positive airway pressure requires that the client generate force to take spontaneous breaths (D) Pressure support ventilation requires that the client generate force to take spontaneous breaths.
A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask
B. Venturi mask Rationale: A venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered
A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of hte followig statements by the client indicates an understanding of the teaching? A. "This medication can increase my blood sugar levels." B. "This medication can decrease my immune response." C. "I can have an increase in my hear rate while taking this medication." D. "I can have mouth sores while taking this medication."
C. "I can have an increase in my heart rate while taking this medication." Rationale: Bronchodilators, such as albuterol, can cause tachycardia
A nurse in a clinic is treating a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding the teaching? A. "This medication will relieve my symptoms by causing my blood vessels to dilate." B. "I should take this medication daily to prevent the headache from occurring." C. "I should expect facial flushing when I take this medication." D. "This medication will lower my sensitivity to food triggers."
C. "I should expect facial flushing when I take this medication." Rationale: Zolmitriptan can cause facial flushing, tingling, and warmth
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button to I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop after I use this device." D. "I will ask my son to push the dose button when I am sleeping."
C. "I should tell the nurse if the pain doesn't stop after I use this device." Rationale: The nurse should identify that PCA is a method of delivering pain medication through an electronic infusion device that allows the client to self-administer pain medication on an as-needed basis. If the client is not achieving adequate pain control, he should let the nurse know so that she can initiate a reevaluation of the client's pain management plan.
A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding of the teaching? A. "I will decrease my fluid intake which taking this medication." B. "I will expect to have black, tarry stools." C. "I will take my medication with meals." D. "I will monitor for weight loss while on this medication."
C. "I will take my medication with meals." Rationale: The client should take this medication with food. Taking prednisone on an empty stomach can cause gastrointestinal distress
A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse? A. "It can spread to breasts and kidneys." B. "It can develop in your gastrointestinal tract." C. "It is limited to brain tissue." D. "It probably started in another area of your body and spread to your brain."
C. "It is limited to brain tissue." Rationale: Benign brain tumors develop from the meninges or cranial nerves and do not metatasize
A nurse is providing teaching to the partner of an older adult client who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective? A. "This medication should increase my husband's appetite." B. "This medication should help my husband sleep better." C. "This medication should help my husband's daily function." D. "This medication should increase my husband's energy level."
C. "This medication should help my husband's daily function." Rationale:Donepezil helps slow the progression of AD and can help improve behavior and daily functions.
A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi medication regimen. Which of the following instructions should the nurse give the client related to ethambutol? A. "Your urine can turn a dark orange." B. "watch for a change in the sclera of your eyes." C. "Watch for any changes in vision." D. "Take vitamin B6 daily."
C. "Watch for any changes in vision." Rationale: The client who is receiving ethambutol will need to watch the visual changes due to optic neuritis, which can result from taking this medication
A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? A. "You might notice yellowing of your skin." B. "You might experience pain in your joints." C. "You might notice tingling of your hands." D. "You might experience a loss of appetite."
C. "You might notice tingling of your hands." Rationale: Tingling of the hands in an adverse effect of isoniazid
A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? A. "It is safe to use microwaves that are 1,200 watts or less." B. "You should avoid the use of CT scans with contrast." C. "You should place a magnet over the implantable device when you feel an aura occurring." D. "It is recommended that you use ultrasound diathermy for pain management."
C. "You shuld place a magnet over the implantable device when you feel an aura occurring." Rationale: The nurse should instruct the client to hold a magnet over the implantable device when an aura occurs so as to decrease seizure activity.
A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (Select all that apply). A. Eye pain B. Floating sports C. Blurred vision D. White pupils E. Bilateral red reflexes
C. Blurred vision D. White pupils Rationale: (C) Blurred vision is a manifestation associated with cataracts (D) White pupils are a manifestation associated with cataracts
A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (Select all that apply). A. Urinary incontinence. B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea.
C. Bradypnea D. Orthostatic hypotension E. Nausea. Rationale: (C) Respiratory depression, which causes respiratory rates to drop to dangerously low levels, is a common adverse effect of opioid analgesia (D) Dizziness or lightheadedness when changing positions is a common adverse effect of opioid analgesia (E) Nausea and vomiting are common adverse effects of opioid analgesia
A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception
C. Inability to recognize familiar objects Rationale: A client who experienced a left-hemispheric stroke will demonstrate the inability to recognize familar objects, known as agnosia
A nurse is assessing a client who is reporting pain despite analgesia. Which of the following actions should the nurse take to assess the intensity of the client's pain? A. Ask the client what precipitates his pain. B. Question the client about the location of his pain. C. Offer the client a pain scale to measure his pain D. Use open-ended questions to identify the sensation of his pain.
C. Offer the client a pain scale to measure his pain Rationale: The nurse should use a pain scale to help the client measure the amount of pain he has and its intensity.
A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response
C. Oxygen saturation Rationale: Using the airway, breathing and ciculation (ABC) priority-setting framework, assessment of oxygen saturation is the priority action. Brain tissue can only survive for 3 minutes before permanent damage occurs
A nurse is caring for a client who displays signs of stage III Parkinson's disease. Which of the following actions should the nurse include in the plan of care? A. Recommend a community support group B. Integrate a daily exercise routine C. Provide a walker for ambulation D. Perform ADLs for the client.
C. Provide a walker for ambulation Rationale: The client should use a walker for ambulation in stage III of Parkinson's disease because movement slows down significantly and gait disturbances occur.
A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care? A. Take quick breaths upon inhalation. B. Place year hand over your stomach C. Take a deep breath in through your nose D. Puff your checks upon exhalation
C. Take a deep breath in through your nose Rationale: The client should take a deep breath in through her nose while performing pursed-lip breathing. This controls the client's breathing.
A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. Which of the following information should the nurse include? A. Consider taking oral contraceptives when on this medication. B. Watch for receding gums when taking the medications. C. Take the medication at the same time every day. D. Provide a urine sample to determine the therapeutic levels of the medication.
C. Take the medication at the same time every day. Rationale: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness.
A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of following information should the nurse include? A. The vaccine is indicated to reduce the risk of respiratory infection. B. The vaccine is administered in a series of four doses. C. The vaccine is recommended for adolescents before starting college D. The vaccine is initially given at 2 months of age.
C. The vaccine is recommended for adolescents before starting college Rationale: The nurse should identify that the meningococcal vaccine is recommended for adolescents prior to starting college due to the increased risk for infection in communal living facilities
A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will place the adapter on my finger to read my blood oxygen saturation level." B. "I will lie on my back with my knees bent." C. "I will rest my hand over my abdomen to create resistance." D. "I will take in a deep breath and hold it before exhaling."
D. "I will take in a deep breath and hold it before exhaling." Rationale: The client who is using the spirometer should take in a deep breath and hold it for 3 to 5 seconds before exhaling. As the client exhales, the needle of the spirometer rises. This promotes lung expansion
A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the findings of migraine headaches? A. "Do the headaches occur at the same time each day?" B. "Is your headache accompanied by profuse facial sweating?" C. "Does your headache occur on one side of your head?" D. "Is there a pattern of headaches among family members?"
D. "Is there a pattern of headaches among family members?" Rationale: A familial pattern of headaches is a common finding with migraines
A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A. "This medication will help you with your tremors." B. "This medication will help you with you bladder function." C. "This medication may cause your skin to bruise easily." D. "This medication may cause your skin to appear yellow in color."
D. "This medication may cause your skin to appear yellow in color." Rationale: Dantrolene and tizanidine are antispasmodic medications that are given to clients who have MS to treat muscle spasms. An adverse effect of this medication is a yellow appearance of the skin, also known as jaundice. The nurse should instruct the client to monitor for this finding, as this can be an indication of impaired liver function.
A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? A. "You can resume playing golf in 2 days." B. "You need to tilt your head back when washing your hair." C. "You can get water in your eyes in 1 day." D. "You need to limit your housekeeping activities."
D. "You need to limit your housekeeping activities." Rationale: The nurse should instruct the client to limit housekeeping activities following cataract surgery. This activity could cause a rise in IOP or injury to the eye.
A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? A. Use music therapy for relaxation with the onset of he headache. B. Increase physical activity when a headache is present C. Drink beverages that contain artifical sweeteners to prevent headaches D. Apply a cool cloth to the face during a headache
D. Apply a cool cloth to the face during a headache Rationale: A cool cloth placed over the client's eyes provides comfort and can relieve pain
A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted B. Monitor ventilator settings every 8 hr. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 1 to 2 hr.
D. Assess breath sounds every 1 to 2 hr. Rationale: The nurse should assess the breath sounds of a client on mechanical ventilation every 1 to 2 hr.
A nurse working in a long-term care facility is planning care for a client in stage V of Alzheimer's disease. Which of the following interventions should be included in the plan of care? A. Use a gait belt for ambulation B. Thicken all liquids C. Provide protective undergarments. D. Assist with ADLs.
D. Assist with ADLs. Rationale: A client in Alzheimer's disease stage V requires assistance of ADLs as increasing cognitive deficits emerge
A nurse is caring for a client 2 hr after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer? A. Antibiotic B. Beta-blocker C. Antiviral D. Beta2 agonist
D. Beta2 agonist Rationale: The nurse should administer a beta2, agonist, which causes dilation of the bronchioles to relieve symptoms
A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms
D. Bronchospasms Rationale: Bronchospasms can indicate the client is having difficulty maintaining a patent airway. The nurse should notify the provider immediately
A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? A. Pearly, gray tympanic membrane (TM) B. Malleus visible behind the TM C. Presence of soft cerumen in the external canal D. Fluid bubble seen behind the TM
D. Fluid bubble seen behind the TM Rationale: Fluid behind the TM indicates the possibility of otitis media and is not an expected finding
A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse? A. Teach the client to walk more quickly when ambulating. B. Complete passive range-of-motion exercises daily. C. Place the client on a low-protein, low-calorie diet D. Give the client extra time to perform activities
D. Give the client extra time to perform activities Rationale: Bradykinesia is an abnormally slowed movement and is seen in clients who have PD. The client should be given extra time to perform activities and should be encouraged to remain active.
A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to assess for this sign? A. Stroke the lateral aspect of the sole of the foot B. Ask the client to blink his eyes C. Observe the facial drooping D. Have the client stand erect with eyes closed
D. Have the client stand erect with eyes closed Rationale: A positive Romberg sign is indicated when a client loses his balance while attempting to stand erect with his eyes closed.
A nurse is caring for a client who experienced a cervical spine injury 24 hr. ago. Which of the following types of prescribed medications should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants
D. Muscle relaxants Rationale: The nurse should clarify with the provider the need for the client to receive muscle relaxants. The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.
A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? A. Most clients exaggerate their level of pain. B. Pain must have an identifiable source to justify the use of opioids. C. Objective data are essential in assessing pain. D. Pain is whatever the client says it is.
D. Pain is whatever the client says it is. Rationale: The nurse should identify that pain is a subjective experience, and the client is the best source of information about it.
A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjunctiva D. Palpation of the orbital areas
D. Palpation of the orbital areas Rationale: Palpation of the orbital, frontal, and facial areas will elicit a report of tenderness, which is a manifestation in a client who has sinusitis
A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise
D. Respiratory compromise Rationale: When using the airway, breathing, and circulation (ABC) approach to client care, the priority complication is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention.
A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected finding? A. Presence of a purulent lesion in the external ear canal B. Feeling of pressure in the ear C. Bulging, red bilateral tympanic membranes D. Unilateral hearing loss
D. Unilateral hearing loss Rationale: Unilateral sensorineural hearing loss is an expected finding in Meniere disease.
