Ch.37 Review Q's (NCLEX Style)

A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam (Valium) 0.25 mg/kg. How many milligrams will be given to this client? _______________________________ mg

15

The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?

Administer medications at exact intervals ordered.

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?

An absence seizure

The client with Guillain-BarrÈ syndrome is scheduled for plasmapheresis and is questioning how this process works. Which of the following statements by the nurse best describes plasmapheresis in the management of this syndrome?

Antibodies that triggered the autoimmune response are removed from your blood.î

A client is admitted for scheduled gamma-knife radiosurgery, in the treatment of a brain tumor. Which nursing measure is primary in the postsurgical care of this client?

Assess neurological findings.

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor

The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care?

Clients and families are the focus of hospice care.î

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Drooping eyelids

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Elevate the head of the bed.

A client, who was adopted at birth, recently discovers that Huntington's disease is prevalent in the biological family history. How can the nurse best assist the client in dealing with personal fears?

Encourage client to verbalize fears.

The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client?

Explaining hospice care and services

You are caring for a client with an inoperable brain tumor. What is a major threat to this client?

Increased ICP

A client, with a recent closed head injury, began experiencing partial (focal) seizures and asks the nurse to explain why this is happening. Which is the best response from the nurse?

It is not uncommon for seizure activity to occur after head trauma.î

Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

Lethargy

Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease?

Maintaining a safe environment

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?

My children are at greater risk to develop this disease.î

A client you are caring for experiences a seizure. What would be a priority nursing action?

Protect the client from injury.

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?

Suicidal ideations

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest?

Take small meals of nutrient and calorie-dense food.

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?

Turn client to side-lying position.

A client with increased intracranial pressure is receiving mannitol (Osmitrol) via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment?

Urine output is increased.

Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy?

Use ophthalmic lubricant and protect the eye.

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply.

Cloudy cerebral spinal fluid Purpura of hands and feet

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?

Damage to the nerves that facilitate vision and hearing

Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply.

Elevated systolic blood pressure Wide pulse pressure

A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client?

Hopelessness

The nurse is caring for a client with Guillain-BarrÈ syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds

You are the nurse caring for a client with Guillain-BarrÈ syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should you keep always ready at the bedside?

Intubation tray and suction apparatus

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Mannitol (Osmitrol)

The client is switched to a different dose of carbidopa-levodopa (Sinemet). Which nursing assessment is primary during this time of medication change?

Monitor vital sign fluctuation.

A client is receiving baclofen (Lioresal) for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following?

Muscle spasms

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?

Seizure was 1 minute in duration including tonic-clonic activity.

The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline (Eldepryl) with carbidopa-levodopa (Sinemet) to the medication regime should result in which purpose?

Slows the progression of the disease

The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client?

Vector bites