CAQ N326 assn #5

During a home visit, a nurse discovers that a child in the household has a disability and has been experiencing seizures. In addition, the child's parent is indifferent to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. The nurse believes that an intervention by an appropriate community resource is indicated. Where should the nurse direct the referral? 1 Outpatient clinic 2 Hospital pediatric unit 3 Child Protective Services 4 Bureau of the handicapped

3

A 50-year-old male client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior? 1 Ask the wife how she knows how the client feels. 2 Instruct the wife to let the client answer for himself. 3 When the wife leaves return to speak with the client. 4 Acknowledge the wife but look at the client for a response.

4

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? 1 Urinary output 2 Sensation to touch 3 Neurologic status 4 Respiratory exchange

4

A client reports intolerance to music played at sound levels that do not bother other people. On assessing, the nurse observes impaired hearing in one ear. What could be the possible condition of the client? 1 Vertigo 2 Tinnitus 3 Hyperopia 4 Hyperacusis

4

A client with parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic, the client complains of some numbness in the left hand. What is the nurse's priority intervention? 1 Refer the client to the primary healthcare provider only if other neurologic deficits are present. 2 Ask the primary healthcare provider to increase the client's dosage of the anticholinergic medication. 3 Stress the importance of having the client call the primary healthcare provider as soon as possible. 4 Make arrangements immediately for further medical evaluation by the client's primary healthcare provider.

4

The nurse provides discharge teaching to a client who had a transurethral vaporization of the prostate. Which statement by the client indicates successful learning? 1 "I should sit for several hours daily." 2 "I should attempt to void every 2 hours when I'm awake." 3 "I should avoid vigorous exercise for 6 months after surgery." 4 "I should notify my primary healthcare provider if my urinary stream decreases."

4

A client is diagnosed as having expressive aphasia. Which type of impairment does the nurse expect the client to exhibit? 1 Speaking or writing 2 Following specific instructions 3 Understanding speech or writing 4 Recognizing words for familiar objects

1

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care? 1 Aspiration 2 Dehydration 3 Nutritional imbalance 4 Impaired communication

1

Which structure is a component of the auditory ossicles? 1 Malleus 2 Vestibule 3 Tympanic membrane 4 External acoustic meatus

1

A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. Which information should the nurse share with the family? 1 Speak louder than usual during visits while looking directly at the client. 2 Encourage the client to speak while allowing time to respond. 3 Give positive reinforcement for correct communication. 4 Tell the client to use the correct words when speaking.

2

Which test helps a primary healthcare provider distinguish between conductive and sensorineural hearing loss? 1 Whisper test 2 Weber test 3 Tympanometry 4 Electrocochleography

2

The nurse is performing an assessment of a female client's reproductive system. Which action should the nurse take? 1 Maintain friendly demeanor with the client during assessment 2 Ask about sexual practices at the beginning of assessment 3 Ask about menstrual history at the beginning of assessment 4 Maintain gender-specific terms while questioning during assessment

3

When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve? 1 Third 2 Fourth 3 Second 4 Seventh

1

A male client reports dysuria, nocturia, and difficulty starting the urinary stream. A cystoscopy and biopsy of the prostate gland have been scheduled. After the procedure the client reports an inability to void. Which action should the nurse take? 1 Insert a urinary retention catheter. 2 Palpate above the pubic symphysis. 3 Limit oral fluids until the client voids. 4 Assure the client that this is expected.

2

A client is diagnosed as having invasive cancer of the bladder, and brachytherapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of this therapy? 1 Decrease in urine output 2 Increase in pulse strength 3 Shrinkage of the tumor on scanning 4 Increase in the quantity of white blood cells (WBCs)

3

A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation? 1 Physical therapy 2 Speech exercises 3 Fitting with a vertebral brace 4 Follow-up on cataract progression

1

The nurse finds that a client with a urinary disorder has very pale-yellow-colored urine. What is the significance of this abnormal finding? 1 It indicates dilute urine. 2 It indicates blood in the urine. 3 It indicates concentrated urine. 4 It indicates the presence of myoglobin.

1

The nurse is reviewing a client's current medication therapy and suspects hematuria. Which medication is responsible for the client's condition? 1 Warfarin 2 Cimetidine 3 Phenazopyridine 4 Nitrofurantoin

1

To help prevent a cycle of recurring urinary tract infections in a female client, which instruction should the nurse share? 1 "Urinate as soon as possible after intercourse." 2 "Increase your daily intake of citrus juice." 3 "Douche regularly with alkaline agents." 4 "Take bubble baths regularly."

1

What is the cup-like structure that collects a client's urine and is located at the end of each papilla? 1 Calyx 2 Capsule 3 Renal cortex 4 Renal columns

1

When completing a neurologic assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion? 1 Inability to stand with feet together when eyes are closed 2 Fanning of toes when the sole of the foot is firmly stroked 3 Dilation of pupils when focusing on an object in the distance 4 Movement of eyes toward the opposite side when head is turned

1

A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery? 1 "Urinary control may be permanently lost to some degree." 2 "An indwelling urinary catheter is required for at least a day." 3 "Your ability to perform sexually will be impaired permanently." 4 "Burning on urination will last while the cystostomy tube is in place."

2

A registered nurse assesses a client's electronic medical record (EMR) and observes increased blood pressure, severe myopia, and blood glucose levels. Which type of eye disorder will the nurse most likely observe written in the EMR? 1 Cataract 2 Glaucoma 3 Corneal abrasions 4 Keratoconjunctivitis sicca

2

Immediately after cataract surgery a client reports feeling nauseated. What should the nurse do? 1 Provide some dry crackers to eat 2 Administer the prescribed antiemetic 3 Explain that this is expected after surgery 4 Encourage deep breathing until the nausea subsides

2

Which visual system assessment technique provides a magnified view of the retina and optic nerve head? 1 Keratometry 2 Ophthalmoscopy 3 Visual acuity testing 4 Confrontation visual filed test

2

A client with a diagnosis of polyarteritis nodosa asks the nurse for information about this disorder. What information should the nurse include in the response? 1 Clients with this disease have an excellent prognosis. 2 The disorder affects males and females in equal numbers. 3 The disorder is considered one of hypersensitivity, and the exact cause is unknown. 4 Clients with this disease have problems with only the kidneys and the retina of the eyes.

3

A client with chronic renal failure has been on hemodialysis for 2 years. The client communicates with the nurse in the dialysis unit in an angry, critical manner and is frequently noncompliant with medications and diet. The nurse can best intervene by first considering that the client's behavior is most likely for which reason? 1 An attempt to punish the nursing staff 2 A constructive method of accepting reality 3 A defense against underlying depression and fear 4 An effort to maintain life and to live it as fully as possible

3

What does the presence of ketones in the urine of a client with renal dysfunction indicate? 1 Cystitis 2 Heart failure 3 Urinary calculi 4 Anorexia nervosa

4

During discharge teaching, a client with an ileal conduit asks how frequently the urine pouch should be emptied. Which reply by the nurse is best? 1 "To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours." 2 "To prevent skin irritation, it should be emptied every hour if any urine has collected in the bag." 3 "To reduce the risk of infection, the system should be opened as little as possible; two times a day is adequate." 4 "To reduce the cost of drainage pouches, it should be emptied once the system is switched to a bedside collection bag."

1

A client is to have hemodialysis. What must the nurse do before this treatment? 1 Obtain a urine specimen to evaluate kidney function. 2 Weigh the client to establish a baseline for later comparison. 3 Administer medications that are scheduled to be given within the next hour. 4 Explain that the peritoneum serves as a semipermeable membrane to remove wastes.

2

Which hearing disorder is most common in women? 1 Tinnitus 2 Hyperacusis 3 Otosclerosis 4 Meniere's disease

3

Which drug prescribed to a client with a urinary tract infection (UTI) turns urine reddish-orange in color? 1 Amoxicillin 2 Ciprofloxacin 3 Nitrofurantoin 4 Phenazopyridine

4

While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which condition should the nurse record in the assessment findings? 1 Decortication 2 Pronator drift 3 Babinski's sign 4 Decerebration

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