Evolve - Med Surg - Cardio, Chapter 69: Management of Patients with Autoimmune disorders RV, Pharmacology (Hesi)
2
A nurse administers the drug desmopressin acetate (DDAVP) to a client with diabetes insipidus. What should the nurse monitor to evaluate the effectiveness of the drug? 1 Arterial blood pH 2 Intake and output 3 Fasting serum glucose 4 Pulse and respiratory rates
A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?
Suction machine with catheters -MS weakens the respiratory muscles & impairs swallowing --> risk for aspiration
Which of the following is the first-line therapy for myasthenia gravis (MG)?
Pyridostigmine bromide (Mestinon)
After sustaining multiple internal injuries when hit by a motor vehicle, a client has a sudden drop in blood pressure to 80/60 mm Hg. What does the nurse determine probably caused this response?
Reduction in circulating blood volume
A client admitted to the hospital for chest pain is diagnosed with angina. The nurse should teach the client that the most common characteristic of anginal pain is that it is:
Relieved by rest
A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI?
I am trying to quit smoking and have a patch on
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, the nurse expects the client to state:
"I have trouble breathing when I walk rapidly."
A client develops a non-healing ulcer of a lower extremity and complains of leg cramps after walking short distances. The client asks the nurse what causes these leg pains. The nurse's best response is:
"Pain occurs in the legs while walking because there is a lack of oxygen to the muscles."
A nurse is discussing discharge instructions with a client who had a coronary artery bypass graft (CABG). The client states, "My spouse is afraid to have sex with me. When will it be safe to have sex again?" Which is the most appropriate response by the nurse?
"You can resume sexual activity as soon as you can climb one flight of stairs without fatigue or discomfort."
A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide?
"You must avoid stress and extreme fatigue, because these can trigger a relapse"
A client experiences elevated triglycerides and cholesterol. The client appears discouraged and says, "Well, I guess I'd better cut out all the fat and cholesterol in my diet." Which is the nurse's most appropriate response?
"You need some fat to supply the necessary fatty acids, so it's mainly just a need to cut down on the amount of fat you consume."
At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.
-Bradycardia -Hypertension -Bradypnea
A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply.
-Confusion -Sudden numbness -Visual disturbances
A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention?
A 60 year old African American man
2
A 67-year-old client has tested positive for influenza A. The client also has asthma. Which drug would the nurse recommend be avoided in this client? 1 Ribavirin 2 Zanamivir 3 Oseltamivir 4 Amantadine
4
A client is prescribed metformin extended release to control type 2 diabetes mellitus. Which statement made by this client indicates the need for further education? 1 "I will take the drug with food." 2 "I must swallow my medication whole and not crush or chew it." 3 "I will notify my doctor if I develop muscular or abdominal discomfort." 4 "I will stop taking metformin for 24 hours before and after having a test involving dye."
3
A client is receiving penicillin G and probenecid for syphilis. What rationale should the nurse give for the need to take these two drugs? 1 Each drug attacks the organism during different stages of cell multiplication. 2 The penicillin treats the syphilis, whereas the probenecid relieves the severe urethritis. 3 Probenecid delays excretion of penicillin, thus maintaining blood levels for longer periods. 4 Probenecid decreases the potential for an allergic reaction to penicillin, which treats the syphilis
1
A client will be taking nitrofurantoin 50 mg orally every evening at home to manage recurrent urinary tract infections. What instructions should the nurse give to the client? 1 Increase the intake of fluids. 2 Strain the urine for crystals and stones. 3 Stop the drug if urinary output increases. 4 Maintain the exact time schedule for taking the drug
2
A client with a history of malabsorption syndrome is admitted to the hospital for medical management. Total parenteral nutrition (TPN) has been prescribed. What action will the nurse take to prevent a major reaction to the TPN infusion? 1 Record the intake and output. 2 Administer the infusion slowly. 3 Change the site every 24 hours. 4 Check the vital signs every 4 hours
1
A client with diabetes asks how exercise will affect insulin and dietary needs. What information does the nurse share about insulin and exercise? 1 "Exercise increases the need for carbohydrates and decreases the need for insulin." 2 "Exercise increases the need for insulin and increases the need for carbohydrates." 3 "Regular physical activity decreases the need for insulin and decreases the need for carbohydrates." 4 "Intensive physical activity decreases the need for carbohydrates but does not affect the need for insulin."
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?
A disorder in which killer T cells and autoantibodies attack or destroy natural cells- those cells that are "self"
A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition?
A failure of the circulatory pump
2
A nurse administers beclomethasone by inhalation to a client with asthma, and the client asks why this medication is necessary. What should the nurse explain is the purpose of this pharmacologic therapy? 1 Promotes comfort 2 Decreases inflammation 3 Stimulates smooth muscle relaxation 4 Reduces bacteria in the respiratory tract
4
A nurse is caring for a client who has been taking several antibiotic medications for a prolonged time. Because long-term use of antibiotics interferes with the absorption of fat, what prescription does the nurse anticipate? 1 High-fat diet 2 Supplemental cod liver oil 3 Total parenteral nutrition (TPN) 4 Water-soluble forms of vitamins A and E
A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse?
Accept the patient's behavior and do not take it personally.
Myasthenia gravis occurs when antibodies attack which receptor sites?
Acetylcholine
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?
Administer atropine to control the SE of edrophonium
A client is suspected to have bacterial meningitis. What is the priority nursing intervention?
Administer prescribed antibiotics
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 -more common in children -brief loss of consciousness; physical activity ceases -sx: stares blankly, eyelids flutter, lips move, slight movement of head/arm/legs, for a few seconds
A nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke?
An obese woman with a history of atrial fibrillation and type 2 diabetes -risk factors for stroke: obesity, atrial fibrillation, type 2 diabetes
A client asks a nurse why captopril (Capoten) was prescribed. What specific drug classification should the nurse include in the explanation to the client?
Antihypertensive
What should the nurse assess to determine if a client is experiencing the therapeutic effect of valsartan (Diovan)?
Blood pressure
A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first?
Cervical
The nurse provides medication discharge instructions to a client who received a prescription for digoxin (Lanoxin) following the client's myocardial infarction. The nurse concludes that the teaching was effective when the client says, "I should:
Check my radial pulse rate daily.
A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with a history of:
Childhood strep throat
The nurse is conducting a nutrition class for a group of clients with congestive heart failure (CHF). It would be most important for the nurse to explain the importance of:
Choosing fresh or frozen vegetables instead of canned ones
Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?
Clonus
The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect?
Constricted pupils
The nurse is caring for a client that is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear what lung sounds?
Crackles
2
Daily regular insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 am. When should the nurse monitor the client for a potential hypoglycemic reaction? 1 At breakfast 2 Before lunch 3 Before dinner 4 In the early afternoon
When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?
Decerebrate
If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit
Decreased muscle tone -patient with upper motor neuron lesions have: hyperactive reflexes, no muscle atrophy, muscle spasticity
A client with rheumatoid arthritis has been taking a steroid medication for the past year. For which complication of prolonged use of this medication should the nurse assess the client?
Decreased white blood cells
A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities?
Elevate the legs.
A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion?
Emboli associated with atrial fibrillation
While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?
Facial pain in the areas of the fifth cranial nerve
Which is often the most disabling clinical manifestation of multiple sclerosis?
Fatigue
The nurse is reviewing a teaching plan for a client that has been prescribed a 2-gram sodium diet. The plan should include which foods that are low in sodium?
Fruits and juices
Cranial nerve IX is also known as which of the following?
Glossopharyngeal
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?
Headache and nuchal rigidity -hyporeflexia= Guillain-Barre syndrome -Ptosis & diplopia = myasthenia gravis
Which terms refers to blindness in the right or left half of the visual field in both eyes?
Homonymous hemianopsia
A client is recovering from a myocardial infarction. Before developing the client's teaching plan, it is important for the nurse to:
Identify the learning needs of the client
The nurse is providing teaching to a client who is scheduled for a cardiac catheterization via the femoral approach. The teaching includes that the client will be:
In the supine position with the affected leg extended for several hours postprocedure.
A client is admitted with a higher than expected red blood cell (RBC) count. What physiological alteration does the nurse expect will result from this clinical finding?
Increased blood viscosity
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?
Initiate seizure precautions.
A patient with epilepsy is having a seizure. Which of the following should the nurse do after the seizure?
Keep the patient to one side
1
Loratadine, 10 mg by mouth once a day in the morning, is prescribed for a 15-year-old girl with hay fever. The girl tells the school nurse that she is concerned that she will be sleepy for a quiz the next day. How should the nurse respond? 1 By explaining that this medication rarely causes drowsiness 2 By advising her to take half a tablet in the morning before school 3 By suggesting that she skip the next day's dose if she can tolerate the hay fever 4 By recommending that she call the allergist for a prescription containing a stimulant
An 85-year-old client has a serum potassium level of 6.7 mEq/L. Which nursing action is a priority at this time?
Monitor for cardiovascular irregularities
A client with a history of type 1 diabetes is diagnosed with heart failure. Digoxin (Lanoxin) is prescribed. When administering the medication, the nurse should:
Monitor the client for atrial fibrillation and first-degree heart block
A child with a congenital heart defect has a cardiac catheterization. What is an essential element of nursing care after this procedure?
Monitoring the extremity distal to the insertion site
The nurse is assessing a client for signs of right ventricular failure. What should the nurse expect if this occurs?
Neck vein distention
The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe?
Ptosis and diplopia -initial manifestation of MG: involves ocular muscles -GB syndrome: muscle weakness & hyporeflexia
A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure?
Remain prone for 2 to 3 hours
A nurse witnesses a person fall. The person becomes unresponsive and pulseless. The nurse plans to use an automated external defibrillator (AED) that is available on site. What should the nurse do first?
Remove any medication patches
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team?
Spouse
Which cerebral lobe contains the auditory receptive areas?
Temporal
A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose?
The muscles will become fatigued and the patient will not be able to chew food or swallow pills. -pyridostigmine= anti cholinesterase medication --> stabilize muscle strength delay= exacerbate muscle weakness
A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?
Trigeminal neuralgia (CN V)
1
Which first line medication would the nurse state is used to treat anaphylactic reactions? 1 Epinephrine 2 Norepinephrine 3 Dexamethasone 4 Diphenhydramine
The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?
cerebral angiography
While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivate nurses to offer the best care possible is preventing:
complications
The initial sign of increasing intracranial pressure (ICP) includes
decreased LOC
Lower motor neuron lesions cause
flaccid muscles
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?
immediately
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the
supine position with the head slightly elevated
2,3,6
What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? Select all that apply 1 Diuresis 2 Pain relief 3 Antipyresis 4 Bronchodilation 5 Anticoagulation 6 Reduced inflammation
2
A nurse determines that the teaching about the side effects of azithromycin has been understood when the adolescent client identifies which problem as the most common side effect of this medication? 1 Tinnitus 2 Diarrhea 3 Dizziness 4 Headache
An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's responses?
Intermittent claudication
A client is receiving warfarin (Coumadin). Which test result should the nurse use to determine if the daily dose of this anticoagulant is therapeutic?
International Normalized Ratio (INR)
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?
"Have you experienced any viral infections in the last month?"
The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm?
"Your physician wants to evaluate the location and condition of the aneurysm"
A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?
unequal response
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
"The paralysis caused by this disease is temporary"
3
A client admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease has received a prescription for a medication that is delivered via a nebulizer. When teaching about use of the nebulizer, the nurse should teach the client to do what? 1 Hold the breath while spraying the medication into the mouth. 2 Position the lips loosely around the mouthpiece and take rapid, shallow breaths. 3 Seal the lips around the mouthpiece and breathe in and out, taking slow, deep breaths. 4 Inhale the medication from the nebulizer, remove the mouthpiece from the mouth, and then exhale.
3
A client newly diagnosed with diabetes arrives at the emergency department complaining of dizziness and weakness. The client's spouse reports that the client has been confused since this morning. The spouse reports that the client administered the morning dose of 10 units of regular insulin and 25 units of NPH insulin with difficulty and did not eat much breakfast. What does the nurse identify as the most likely cause of the client's signs and symptoms? 1 Hyperglycemia 2 Hyperlipidemia 3 Hypoglycemia 4 Hypocalcemia
1
A client newly diagnosed with type 2 diabetes is receiving glyburide and asks the nurse how this drug works. What mechanism of action does the nurse provide? 1 Stimulates the pancreas to produce insulin 2 Accelerates the liver's release of stored glycogen 3 Increases glucose transport across the cell membrane 4 Lowers blood glucose in the absence of pancreatic function
3
A client receiving intravenous vancomycin reports ringing in both ears. Which initial action should the nurse take? 1 Notify the primary healthcare provider. 2 Consult an audiologist. 3 Stop the infusion. 4 Document the finding and continue to monitor the client
1,2,3
A client with gastroesophageal reflux disease (GERD) receives a prescription for an H2 receptor antagonist. Which medications are within the classification of an H2 receptor antagonist? Select all that apply 1 Nizatidine 2 Ranitidine 3 Famotidine 4 Lansoprazole 5 Metoclopramide
4
A client with hepatitis B asks the nurse, "Are there any medications to help me get rid of this problem?" Which is the best response by the nurse? 1 "Sedatives can be given to help you relax." 2 "We can give you immune serum globulin." 3 "Vitamin supplements are frequently helpful and hasten recovery." 4 "There are medications to help reduce viral load and liver inflammation.
4
A health care provider prescribes daily docusate sodium for a client. The nurse explains to the client that this drug has what action? 1 Lubricates the feces 2 Creates an osmotic effect 3 Stimulates motor activity 4 Lowers the surface tension of feces
2
A health care provider prescribes psyllium 3.5 g twice a day for constipation. What is most important for the nurse to teach this client? 1 Urine may be discolored. 2 Each dose should be taken with a full glass of water. 3 Use only when necessary because it can cause dependence. 4 Daily use may inhibit the absorption of some fat-soluble vitamins
2
A health care provider prescribes ranitidine for a client with heartburn. During a teaching session, which information will the nurse share with the client about how this drug works? 1 Ranitidine increases gastrointestinal peristalsis. 2 Ranitidine reduces gastric acidity in the stomach. 3 Ranitidine neutralizes the acid that is present in the stomach. 4 Ranitidine stops production of hydrochloric acid in the stomach
2
A health care provider prescribes vancomycin peak and trough levels for a client who is receiving vancomycin intravenous piggyback (IVPB). When should the nurse have the laboratory obtain a blood sample to determine a peak level of the antibiotic? 1 Halfway between two doses of the drug 2 Between 30 and 60 minutes after a dose 3 Immediately before the medication is administered 4 Anytime it is convenient for the client and the laboratory
1,3,2,4
A healthcare provider prescribes a medication to be administered via a metered-dose inhaler (MDI) for a young adult with asthma. List in order the steps the nurse teaches the client to follow when using the inhaler. 1. Shake the inhaler for 30 seconds. 2. Hold the inhaler upright in the mouth. 3. Exhale slowly and deeply to empty the air from the lungs. 4. Start breathing in and press down on the inhaler once
3
A healthcare provider prescribes ampicillin for a client with an infection. What information should the nurse include in the teaching plan about this medication? 1 Take the ampicillin with meals. 2 Store the ampicillin in a light-resistant container. 3 Notify the healthcare provider if diarrhea develops. 4 Continue the drug until a negative culture is obtained
1
A healthcare provider prescribes an antibiotic intravenous piggyback twice a day for a client with an infection. The healthcare provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. What reason does the nurse provide? 1 "They determine adequate dosage levels of the drug." 2 "They detect if you are having an allergic reaction to the drug." 3 "The tests permit blood culture specimens to be obtained when the drug is at its lowest level." 4 "These allow comparison of your fever to when the blood level of the antibiotic is at its highest."
4
A healthcare provider prescribes famotidine and magnesium hydroxide/aluminum hydroxide antacid for a client with a peptic ulcer. The nurse should teach the client to take the antacid at what time? 1 Only at bedtime, when famotidine is not taken 2 Only if famotidine is ineffective 3 At the same time as famotidine, with a full glass of water 4 One hour before or 2 hours after famotidine
4
A healthcare provider prescribes ophthalmic drops for a client. What should a nurse include in the instructions for a client learning to self-administer eyedrops? 1 Lie on the unaffected side for administration. 2 Instill drops onto the pupil to promote absorption. 3 Close eyes tightly after administering the eyedrops. 4 Apply pressure to the nasolacrimal duct after instillation
2
A nurse evaluates that a client understands appropriately how to take the antacids prescribed by the primary health care provider when the client makes which statement? 1 "I will take this antacid at the onset of pain." 2 "I will take this antacid 30 minutes after meals." 3 "I will take this antacid every 4 hours around the clock." 4 "I will take this antacid each time I have something to eat."
4
A nurse has provided teaching to a client with a newly prescribed proton pump inhibitor (PPI). The nurse determines that the teaching is effective when the client states that the medication is used for the treatment of which condition? 1 Diarrhea 2 Vomiting 3 Cardiac dysrhythmias 4 Gastroesophageal reflux disease (GERD
3
A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and that the prescription was never filled. What is an appropriate nursing response? 1 Ask the pharmacist to provide a generic form of the medication. 2 Encourage the client to acquire the medication over the Internet. 3 Inform the healthcare provider of the inability to afford the medication. 4 Suggest that the client purchase medical insurance that covers prescription medications
3
A nurse is administering a histamine H2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent? 1 Colitis 2 Gastritis 3 Stress ulcer 4 Metabolic acidosis
1,2,4
A nurse is caring for a female client who is receiving rifampin for tuberculosis. Which statements indicate that the client understands the teaching about rifampin? Select all that apply 1 "This drug may be hard on my liver so I must avoid alcoholic drinks while taking it." 2 "This drug may reduce the effectiveness of the oral contraceptive I am taking." 3 "I cannot take an antacid within 2 hours before taking my medicine." 4 "My healthcare provider must be called immediately if my eyes and skin become yellow.
2
A nurse is caring for several clients with type 1 diabetes, and they each have a prescription for a specific type of insulin. Which insulin does the nurse conclude has the fastest onset of action? 1 NPH insulin 2 Insulin lispro 3 Regular insulin 4 Insulin glargine
2
A nurse is reviewing a newly admitted client's medication administration record (MAR). Which element, if missing, makes the record incomplete? 1 Height 2 Allergies 3 Vital signs 4 Body weight
2
A nurse plans an evening snack of milk, crackers, and cheese for a client who is receiving NPH insulin. What is the purpose of this snack? 1 Encouragement to stay on the diet 2 Food to counteract late insulin activity 3 Added calories to promote weight gain 4 High carbohydrates to provide nourishment for immediate use
A client being treated for hypertension reports having a persistent hacking cough. What class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this client's medications?
Angiotensin-converting enzyme (ACE) inhibitors
The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action?
Ensure atropine is readily available. -atropine to control the Res of medication
A client is scheduled to be transferred from the coronary care unit to a progressive care unit. The client asks a nurse, "Are you sure I'm ready for this move?" What does the nurse conclude the client most likely is experiencing?
Fear
A client takes isosorbide dinitrate (Isordil) daily. The client states, "I would like to start taking sildenafil (Viagra) for erectile dysfunction. I was told I can't take sildenafil and isosorbide dinitrate at the same time." The nurse explains that taking both of these medications concurrently may result in severe:
Hypotension
The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority?
Include client in planning of care and setting of goals
The diagnosis of multiple sclerosis is based on which test?
Magnetic resonance imaging
A client is admitted with stage 2 hypertension. What diastolic pressure does the nurse consider to be consistent with this diagnosis?
More than 100 mm Hg
What should a nurse do to decrease or control the sensory and cognitive disturbances that can occur after a client has open-heart surgery?
Plan for maximum periods of rest
For what client response must the nurse monitor to determine the effectiveness of amiodarone (Cordarone)?
Presence of cardiac dysrhythmias
Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident?
Prevention of joint contractors
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma
4
The nurse is preparing to administer an intravenous piggyback antibiotic that has been newly prescribed. Shortly after initiation, the client becomes restless and flushed and begins to wheeze. The nurse determines the that appropriate priority action will be to stop the antibiotic infusion and then do what? 1 Notify the physician immediately about the client's condition. 2 Take the client's blood pressure. 3 Obtain the client's pulse oximetry. 4 Assess the client's respiratory status
4
The postoperative prescriptions for a client who had repair of an inguinal hernia include docusate sodium daily. Before discharge, the nurse instructs the client about what potential side effect? 1 Rectal bleeding 2 Fecal impaction 3 Nausea and vomiting 4 Mild abdominal cramping
When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data?
When, if any, was your last narcotic use? *when assessing, essential to c heck the use of morphine, heroin, narcotic, CNS depressant
2
Which Food and Drug Administration pregnancy risk category do drugs that have not undergone any studies in animal and pregnant women belong to? 1 Category B 2 Category C 3 Category D 4 Category X
The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?
"I will stretch daily as directed by the physical therapist"
The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? Select all that apply.
-Demonstrate daily muscle stretching exercises -allow the patient adequate time to perform exercises -apply warm compresses to the affected areas
The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply.
-Sudden, severe headache -Vomiting -Seizures -both hemorrhagic + ischemic stroke: numbness/weakness of extremity, altered LOC, loss of balance
2
A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client? 1 Determine the client's emotional state. 2 Give prescribed drugs to promote bronchiolar dilation. 3 Provide education about the impact of a family history. 4 Encourage the client to use an incentive spirometer routinely
3
A client is diagnosed with diabetic ketoacidosis. Which insulin should the nurse expect the health care provider to prescribe? 1 NPH insulin 2 Inhaled insulin 3 Regular insulin 4 Insulin glargine
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?
"Have you experienced any viral infections in the last month?" -*antecedent event (often viral infection) precipitates clinical presentation & usually occurs 2 weeks before symptoms begin. -Ptosis= common sx with myasthenia graves
The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?
"I was brushing my teeth" -paroxysms from: 1) washing the face 2) shaving 3) brushing teeth, eating, drinking
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action?
Form understandable words & comprehend spoken words
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse?
"There are no guarantees, but a large portion of people with Guillain-Barre syndrome survive"
3
A client has severe diarrhea, and the health care provider prescribes intravenous fluids, sodium bicarbonate, and an antidiarrheal medication. Which drug does the nurse expect the health care provider to prescribe? 1 Psyllium 2 Bisacodyl 3 Loperamide 4 Docusate sodium
A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. The best response by the nurse is, "This is probably the result of:
Leakage of red blood cells through the vascular wall."
The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?
CN II
4
Which statement made by a client recently diagnosed with type 1 diabetes indicates that further education is necessary regarding the teaching plan? 1 "I will need to have my eyes and vision examined once a year." 2 "I will need to check my blood sugar at home to evaluate my response to my treatment plan." 3 "I can improve metabolic and cardiac risk factors of this disease if I follow a low-calorie diet and lose weight." 4 "Once I reach my target weight there is a good chance that I will be able to switch from insulin to an oral medication."
1
Which statement regarding treatment with interferon indicates that the client understands the nurse's teaching? 1 "I will drink 2 to 3 quarts (2 to 3 liters) of fluid a day." 2 "Any reconstituted solution must be discarded in 1 week." 3 "I can continue driving my car as long as I have the stamina." 4 "While taking this medicine I should be able to continue my usual activity."
A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates the need for further instruction?
Whole milk with oatmeal
A client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery?
bruit
A neurologic deficit is best defined as a defecit of the:
central and peripheral nervous systems with decreased, impaired, or absent functioning
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise
A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase?
preventing further neurologic damage
The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to
refrain from eating or drinking for now
3
A client has an anaphylactic reaction after receiving intravenous penicillin. What does the nurse conclude is the cause of this reaction? 1 An acquired atopic sensitization occurred. 2 There was passive immunity to the penicillin allergen. 3 Antibodies to penicillin developed after a previous exposure. 4 Potent antibodies were produced when the infusion was instituted
2
Which information should be included in the teaching plan for the elderly client with peptic ulcer disease who is taking an antacid and sucralfate? 1 Antacids should be taken 30 minutes before a meal. 2 Sucralfate should be taken on an empty stomach one hour before meals. 3 Sucralfate is prescribed for the long-term maintenance of peptic ulcer disease. 4 Sodium bicarbonate is an inexpensive over-the-counter antacid with few adverse effects
2
Which nursing action is the priority when administering chelation therapy for a toddler-age client? 1 Assessing vital signs 2 Monitoring urine output 3 Conducting a behavioral assessment 4 Providing education to reduce lead exposure
A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure?
140 to 159 mm Hg
The nurse is caring for a client undergoing chemotherapy for cancer treatment. The client's laboratory results indicate bone marrow suppression. The nurse should encourage the client to:
Use an electric razor when shaving
When supporting vasodilation by the use of warmth for a client with peripheral arterial insufficiency, the nurse cautions the client to avoid:
Using a heating pad to warm the extremities
The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve:
VIII
A client with a neurologic impairment reports having problems with constipation. Which foods might the nurse recommend?
Vegetables
1,2,3,4,5
A nurse is preparing to administer insulin to a client with diabetes. In which order should the nurse perform the actions associated with insulin administration? Correct 2. Rotate the vial of insulin between the palms of the hands. 4 Instill air into the vial of insulin equal to the desired dose. 3. Wipe the top of the insulin vial with an alcohol swab. 5. Withdraw the correct amount of insulin from the inverted vial. 1. Wash hands with soap and water
4
A client develops a fever after surgery. Ceftriaxone is prescribed. For which potential adverse effect should the nurse monitor the client? 1 Dehydration 2 Heart failure 3 Constipation 4 Allergic response
4
A client is admitted to the hospital with a diagnosis of acute pancreatitis. The health care provider's prescriptions include nothing by mouth and total parenteral nutrition (TPN). The nurse explains that the TPN therapy provides what benefit? 1 Is the easiest method for administering needed nutrition 2 Is the safest method for meeting the client's nutritional requirements 3 Will satisfy the client's hunger without the discomfort associated with eating 4 Will meet the client's nutritional needs without causing the discomfort precipitated by eating
4
A client is diagnosed with pulmonary tuberculosis, and the healthcare provider prescribes a combination of rifampin and isoniazid. The nurse evaluates that the teaching regarding the drug is effective when the client reports which action as most important? 1 "Report any changes in vision." 2 "Take the medicine with my meals." 3 "Call my doctor if my urine or tears turn red-orange." 4 "Continue taking the medicine even after I feel better.
2
A senior nurse teaches a nursing student about how to treat poisoning in young children. Which statement by the nursing student indicates the need for further teaching? 1 "An emergency team should be called if the victim stops breathing." 2 "Syrup of ipecac should be administered immediately after poisoning." 3 "The National Poison Control hotline should be called if a poison is ingested." 4 "The child should be removed from the hazardous environment if the poison has been inhaled."
A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?
Cerebellar abscess
The nurse should monitor the client for which clinical finding indicating digoxin toxicity?
Blurred vision
2
After an acute episode of gastrointestinal (GI) bleeding, a client is diagnosed with a gastric ulcer. The client receives a prescription for ranitidine 150 mg twice a day. What concern prompts the nurse to contact the health care provider about the prescription? 1 Ranitidine can increase bleeding risk. 2 An administration route is not specified. 3 Ranitidine is contraindicated for gastric ulcers. 4 The recommended dose is higher than prescribed
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?
Alternatively patch one eye every 2 hours
4
Ampicillin 250 mg by mouth every 6 hours is prescribed for a client who is to be discharged. Which statement indicates to the nurse that the client understands the teaching about ampicillin? 1 "I should drink a glass of milk with each pill." 2 "I should drink at least six glasses of water every day." 3 "The medicine should be taken with meals and at bedtime." 4 "The medicine should be taken one hour before or two hours after meals
A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapherisis and explains this in which of the following statements?
Antibodies are removed from the plasma
Which medication classification is used preoperatively to decrease the risk of postoperative seizures?
Anticonvulsants
The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?
CN I
The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?
CN II (optic nerve)
A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain?
CN V (trigeminal)
The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?
CN XII --> movement of the tongue
A client who is receiving a cardiac glycoside, a diuretic, and a vasodilator has been placed on bed rest. The client's apical pulse rate is 44 beats per minute. The nurse concludes that the decreased heart rate most likely is a result of the:
Cardiac glycoside
The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience?
Dependent edema in the evening
Amlodipine (Norvasc) is prescribed for a client with hypertension. Which response to the medication should the nurse instruct the client to report to the health care provider?
Difficulty breathing
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?
Diplopia and ptosis -initial manifestation of MG: involves ocular muscles
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?
Immediately
1,2,5
In what ways can a nurse prevent medication errors? Select all that apply 1 Avoid using abbreviations and acronyms 2 Minimize the use of verbal and telephone orders 3 Try to guess what the client is saying if the language is not understood 4 Document each dose of the drug using trailing zeros when recording the dose 5 Check three times before giving a drug by comparing the drug order and medication profile
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?
Ischemic
The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia who is scheduled to wear a Holter monitor for 24 hours. During the test, the client should be instructed to:
Keep a diary of activities
A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about post-procedure interventions that protect the catheter insertion site. The nurse instructs the client that the leg used for catheter insertion will be:
Kept extended while on bed rest
The diagnosis of multiple sclerosis is based on which test?
Magnetic resonance imaging (MRI)
Which of the following is accurate regarding a hemorrhagic stroke?
Main presenting symptom is an "exploding headache"
A client is being admitted to a rehabilitation hospital as a result of the tetraplegia caused a stroke. The client's condition is stable, and after admission the client will begin physical and psychological therapy. An important part of nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention?
Maintain sufficient integument capillary pressure
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?
Maintaining a patent airway
A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding?
Oliguria
The most common cause of cholinergic crisis includes which of the following?
Overmedication --> muscle weakness, respiratory impairment, excessive pulmonary secretion -Myasthenic crisis: sudden, temporary exacerbation of MG; common precipitating event= infection
A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care?
Perform a neurovascular assessment every two hours
A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse considers that a distinguishing sign that is unique to a fat embolus is:
Petechiae
A client develops a nosebleed (epistaxis) and seeks treatment at a first-aid station. The nurse can help control the bleeding by:
Pinching the nostrils together
A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take?
Place the client in the supine position and take the vital signs
The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily?
Respiratory
The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:
Right sided paralysis
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 *describing length & progression of seizure= priority
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?
Tension test
The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?
Thrombolytic therapy has a time window of only 3 hours.
The brain stem holds the medulla oblongata. What is the function of the medulla oblongata?
Transmits motor impulses from the brain to the spinal cord
A nurse concludes that the simvastatin (Zocor) being administered to a client is effective. A decrease in what clinical finding supports this conclusion?
Triglycerides
A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is:
Type A or O negative
A nurse is teaching a health class to older adult women about heart disease. The nurse discusses the most common prodromal symptom reported by women with acute coronary heart disease that usually is not experienced by men. What response indicates that a woman understood the teaching?
Unusual fatigue
A client develops severe bone marrow suppression related to cancer treatment. What is important for the nurse to include in the client's teaching?
Use a soft toothbrush for oral hygiene
The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe?
Ptosis and diplopia
1
A client is diagnosed with tuberculosis associated with human immunodeficiency virus infection. What crucial laboratory test results should the nurse review before antitubercular pharmacotherapy is started? 1 Liver function studies 2 Pulmonary function studies 3 Electrocardiogram and echocardiogram 4 White blood cell (WBC) count and sedimentation rate
4
A client is diagnosed with type 2 diabetes, and the health care provider prescribes an oral hypoglycemic. For what side effect should the nurse teach this client to monitor? 1 Ketonuria 2 Weight loss 3 Ketoacidosis 4 Low blood sugar
1
A client is receiving antibiotics and antifungal medications for the treatment of a recurring vaginal infection. What should the nurse encourage the client to do to compensate for the effect of these medications? 1 Eat yogurt with active cultures daily. 2 Avoid spicy foods. 3 Drink more fruit juices. 4 Take a multivitamin every day
4
A client is receiving dexamethasone to treat acute exacerbation of asthma. For what side effect should the nurse monitor the client? 1 Hyperkalemia 2 Liver dysfunction 3 Orthostatic hypotension 4 Increased blood glucose
3
A client is started on tetracycline antibiotic therapy. What should the nurse do when administering this drug? 1 Administer the medication with meals or a snack. 2 Provide orange or other citrus fruit juice with the medication. 3 Give the medication an hour before milk products are ingested. 4 Offer antacids 30 minutes after administration if gastrointestinal side effects occur
4
A client who has a gastric ulcer asks what to do if epigastric pain occurs. The nurse evaluates that teaching is effective when the client makes which statement? 1 "Eliminating fluids with meals will prevent pain." 2 "I will increase my food intake to avoid an empty stomach." 3 "Taking an aspirin with milk will relieve my pain and coat my ulcer." 4 "Taking an antacid preparation will decrease pain due to gastric acid."
1
A client who has been prescribed tetracycline continues the course of treatment during the first trimester of pregnancy. Which teratogenic effect may occur in the fetus? 1 Bone anomalies 2 Central nervous system malformations 3 Facial malformations 4 Internal organ defects
1
A client with a new diagnosis of type 1 diabetes is told that lifelong insulin will be needed. The client becomes agitated and says, "I am scared of shots. If that is my only option, I'll just have to go into a coma and die!" What is the nurse's best response? 1 "Injections are not the only option available for insulin." 2 "It won't be so bad; you will get used to it if you will only try." 3 "This is one of those times when you need to act like an adult." 4 "Clients have the right to refuse treatment, but I need you to sign this form that removes us from liability for your decision."
3
A client with diabetes experiences tremors, pallor, and diaphoresis. What should the nurse consider is a possible cause of these clinical manifestations? 1 Overeating 2 Intestinal virus 3 Aerobic exercise 4 Missed insulin dose
3
A client with gastric ulcer disease asks the nurse why the health care provider has prescribed metronidazole. What purpose does the nurse provide? 1 To augment the immune response 2 To potentiate the effect of antacids 3 To treat Helicobacter pylori infection 4 To reduce hydrochloric acid secretion
2
A client with tuberculosis is started on a chemotherapy protocol that includes rifampin. The nurse evaluates that the teaching about rifampin is effective when the client makes which statement? 1 "I need to drink a lot of fluid while I take this medication." 2 "I can expect my urine to turn orange from this medication." 3 "I should have my hearing tested while I take this medication." 4 "I might get a skin rash because it is an expected side effect of this medication.
1
A client with tuberculosis is to begin combination therapy with isoniazid, rifampin, pyrazinamide, and streptomycin. The client says, "I've never had to take so much medication for an infection before." How will the nurse respond? 1 "This type of organism is difficult to destroy." 2 "Streptomycin prevents side effects of the other drugs." 3 "You'll only need to take the medications for a couple of weeks." 4 "Aggressive therapy is needed because the infection is well advanced."
2
A client with type 1 diabetes requests information about the differences between penlike insulin delivery devices and syringes. What information does the nurse provide about the penlike devices? 1 The penlike devices have a shorter injection time 2 Penlike devices provide a more accurate dose delivery. 3 The penlike delivery system uses a smaller-gauge needle. 4 Penlike devices cost less by having reusable insulin cartridges
1
A client with type 1 diabetes self-administers NPH insulin every morning at 8 am. The nurse evaluates that the client understands the action of the insulin when the client identifies which time range as the highest risk for hypoglycemia? 1. 2 pm to 8 pm 2. 8 pm to noon 3. 9 am to 10 am 4. 10 am to 11 am
4
A client with type 1 diabetes tells the nurse, "I take guaifenesin cough syrup when I have a cold." What important instruction does the nurse include in client teaching about this medication? 1 Substitute an elixir for the cough syrup. 2 Increase fluid intake and use a humidifier to control the cough. 3 The small amounts of sugar in medications are not a concern with diabetes. 4 Include the glucose in the cough syrup when calculating daily carbohydrate allowance
4
A health care provider prescribes bisacodyl for a client with cardiac disease. The nurse explains to the client that this drug acts by what mechanism? 1 Producing bulk 2 Softening feces 3 Lubricating feces 4 Stimulating peristalsis
1
A mother complains that her child's teeth have become yellow in color. With prolonged use, which medication may be responsible for the child's condition? 1 Tetracycline 2 Promethazine 3 Chloramphenicol 4 Fluoroquinolones
2
A nurse administers a tube of glucose gel to a client who is hypoglycemic. What explanation does the nurse share regarding the reversal of hypoglycemia? 1 It liberates glucose from hepatic stores of glycogen. 2 It provides a glucose source that is rapidly absorbed. 3 Insulin action is blocked as it competes for tissue sites. 4 Glycogen is supplied to the brain as well as other vital organs
1,4
A nurse concludes that a client has a hypoglycemic reaction to insulin. Which clinical findings support this conclusion? Select all that apply 1 Irritability 2 Glycosuria 3 Dry, hot skin 4 Heart palpitations 5 Fruity odor of breath
Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?
Apply an eye patch to the right eye.
The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform?
Apply warm packs to the affected area.
The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following?
Approximately 60~75% of clients recover completely.
The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction?
Assess the blood pressure and heart rate
A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity has a femoral angiogram. What is the priority nursing action after the angiogram?
Assess the client's affected extremity
Which nursing intervention is the priority for a client in myasthenic crisis?
Assessing respiratory effort -myasthenic crisis--> severe muscle weakness = lead to respiratory failure & death
Which positions is used to help reduce intracranial pressure (ICP)?
Avoiding flexion of the neck with use of a cervical collar
Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
Speeds nerve impulse transmission -myelin: complex substance covering nerves -axon: carries message to the next nerve cell -neuron: building block of nervous system -neurotransmitter: chemical messenger
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?
Neurovascular system
2
During a teaching session about insulin injections, a client asks the nurse, "Why can't I take the insulin in pills instead of taking shots?" What is the nurse's best response? 1 "Insulin cannot be manufactured in pill form." 2 "Insulin is destroyed by gastric juices, rendering it ineffective." 3 "Your health care provider decides the route of administration." 4 "Your health care provider will prescribe pills when you are ready."
3
During the administration of total parenteral nutrition (TPN), an assessment of the client reveals a bounding pulse, distended jugular veins, dyspnea, and cough. What is the priority nursing intervention? 1 Restart the client's infusion at another site. 2 Slow the rate of the client's infusion of the TPN. 3 Interrupt the client's infusion and notify the healthcare provider. 4 Obtain the vital signs and continue monitoring the client's status
A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has?
Dysfunction of the vagus nerve (CN X)
An older adult tells the nurse, "I read about a vitamin that may be related to aging because of its effect on the structure of cell walls. I wonder whether it is wise to take it." The nurse concludes the client probably is referring to:
E
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?
Edrophonium (Tensilon)
A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test?
Edrophonium (Tension) -with MG, demonstrate a marked improvement in muscle tone that lasts about 4 to 5 minutes
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is:
Elevate the head of the bed and obtain vital signs
A nurse is evaluating the results of treatment with erythropoietin (Epogen). Which client response is considered significant?
Elevation in hematocrit level
A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk?
Endocarditis
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?
Left visual field deficit -Left hemispheric stroke --> aphasia, slow & cautious behavior, altered intellectual ability
Bell palsy is a disorder of which cranial nerve?
Facial (VII)
The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?
Facial distortion and pain
4
Famotidine (Pepcid) is prescribed for a client with peptic ulcer disease. The client asks the nurse what this medication does. Which action does the nurse mention when replying? 1 Increases gastric motility 2 Neutralizes gastric acidity 3 Facilitates histamine release 4 Inhibits gastric acid secretion
3
For a client with difficulty swallowing, the nurse should crush which medication? 1 Metoprolol extended release 2 Felodipine sustained release 3 Acetaminophen extra strength 4 Potassium chloride extended release
During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal
The nurse is performing an initial assessment on a client admitted with a possible brain abscess. Which of the following would the nurse most likely find?
Headache that is worse in the morning
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?
Lethargy and stupor
A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis?
Help the client perform ROM exercises every 8 hours
What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who had a cardiac arrest?
How long the client was anoxic
A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified?
Hypertension
A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication?
Kidney failure
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?
Lung auscultation and measurement of vital capacity and tidal volume
The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?
Maintenance of a patent airway.
A client is admitted to the emergency department with chest pain and shortness of breath. An electrocardiogram indicates that the client is experiencing a myocardial infarction. An emergency cardiac catheterization is scheduled. What information should the nurse include in the pre-procedure teaching?
Mild sedation is maintained during the procedure
A nurse provides teaching regarding vitamin B12 injections to a client with pernicious anemia. The nurse concludes that the teaching was understood when the client states, "I must take the drug:
Monthly, for the rest of my life.
A client who is complaining of severe midsternal pain is brought to the emergency department. The client is diagnosed with a myocardial infarction. Which drug can the nurse expect to be prescribed to control this client's pain?
Morphine sulfate (MS Contin)
The Family Nurse Practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?
Moving the head and chin toward the chest
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?
Multiple sclerosis
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?
Multiple sclerosis -cause of MS: unknown, twice more common in women
Which of the following is considered a central nervous system (CNS) disorder?
Multiple sclerosis :immune-mediated, progressive demyelinating disease of the CNS -Guillain Barre, myasthenia gravis, Bell's palsy= peripheral nervous system d/o
The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?
Muscle weakness and hyporeflexia of the lower extremities
3
Naltrexone is used to treat clients with substance abuse problems. In which situation does the nurse anticipate that naltrexone will be administered? 1 To treat opioid overdose 2 To block the systemic effects of cocaine 3 To decrease the recovering alcoholic's desire to drink alcohol 4 To prevent severe withdrawal symptoms from antianxiety agents
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?
Non-contrast computed tomogram (CT scan) --> determine if event is ischemic or hemorrhagic
A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications?
Placement of a feeding tube
A client diagnosed with multiple myeloma has been given a poor prognosis. After discharge, the client plans to travel on an airplane and attend sporting events with friends and family. The nurse prepares a discharge teaching plan for this client and includes:
Preventing infection; the client is at risk for leukopenia
3
Pyridoxine (vitamin B6) and isoniazid (INH) are prescribed as part of the chemotherapy protocol for a client with tuberculosis. Which response indicates to the nurse that vitamin B6 is effective? 1 Weight gain 2 Absence of stomatitis 3 Absence of numbness and tingling in extremities 4 Acceleration of dormant tubercular bacilli destruction
A client who is hospitalized after a myocardial infarction asks the nurse why the client is receiving morphine. The nurse replies that morphine:
Relieves pain and prevents shock
How should the nurse make the bed of a client who is in the acute phase after a myocardial infarction?
Replace the top linen and only the necessary bottom linen.
3
Steroid therapy is prescribed for a client with an exacerbation of ulcerative colitis. The nurse evaluates that teaching is effective when the client identifies which times for the medication schedule? 1 At bedtime with a snack 2 Three times a day with meals 3 In the early morning with food 4 One hour before or two hours after eating
An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?
She is taking coumadin
A client's cardiac monitor shows a PQRST wave for each beat and indicates a rate of 120 beats per minute. The rhythm is regular. The nurse concludes that the client is experiencing:
Sinus tachycardia
A client with stage III-B Hodgkin disease is started on chemotherapy. The nurse teaches the client to notify the health care provider to seek treatment for which response to chemotherapy?
Sores in the mouth
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?
Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone
What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?
Syncope
A 75-year-old client has a baseline blood pressure of 140/90 mm Hg. The nurse obtains a sitting blood pressure in the client's left arm, and the reading is 160/100 mm Hg. What action should the nurse take next?
Take the blood pressure in the right arm, and then take the blood pressure in both arms while the client is standing
A client hospitalized for heart failure is receiving digoxin (Lanoxin) and will continue taking the drug after discharge. What should be included in the plan of care for the next few days?
Taking the apical pulse before drug administration and teaching the client how to count the pulse.
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?
The client is unaware of his left side. You should approach him on the right side.
A client with a long history of bilateral varicose veins questions a nurse about the brownish discoloration of the skin on the lower extremities. What should the nurse include in the response to the client's question?
There is leakage of red blood cells (RBCs) through the vascular wall.
Which client statement indicates an understanding of the nurse's instructions concerning a Holter monitor?
The monitor will record any abnormal heart rhythms while I go about my usual activities.
3
The nurse is preparing to discharge a client who presented to the emergency room for an acute asthma attack. The nurse notes that upon discharge the healthcare provider has prescribed theophylline 300 mg orally to be taken daily at 9:00 AM. The nurse will teach the client to take the medication on which schedule? 1 With a meal 2 Only at bedtime 3 At a specific time prescribed 4 Until symptoms are gone
4
The nurse provides discharge teaching to a client with tuberculosis. Which treatment measure does the nurse reinforce as the highest priority? 1 Getting sufficient rest 2 Getting plenty of fresh air 3 Changing the current lifestyle 4 Consistently taking prescribed medication
2
The nurse provides teaching to a client who has received a prescription for oral pancreatic enzymes, pancrelipase. The nurse evaluates that teaching is understood when the client identifies which time for medication scheduling? 1 At bedtime 2 With meals 3 One hour before meals 4 On arising each morning
What is the most objective way that a nurse can assess the extent of edema in a client?
Weighing the client
4
What information should the nurse include when teaching a client about antacid tablets? 1 Take them at 4-hour intervals. 2 Take them 1 hour before meals. 3 They are as effective as the liquid forms. 4 They interfere with the absorption of other drugs
2,3,4
What interventions are needed to help prevent accidental poisoning of children? Select all that apply 1 Medicines should be referred to as candy. 2 Potent poisons should be kept out of reach of children. 3 Containers of the poisonous substances should be tightly closed. 4 Old unused and unnecessary medications should be safely disposed. 5 Medications should be transferred from their original containers to alternate ones
2
What is the priority goal for a client with asthma who is being discharged from the hospital with prescriptions for inhaled bronchodilators? 1 Is able to obtain pulse oximeter readings 2 Demonstrates use of a metered-dose inhaler 3 Knows the healthcare provider's office hours 4 Can identify the foods that may cause wheezing
2
What should a nurse teach the client to do to avoid lipodystrophy when self-administering insulin therapy? 1 Exercise regularly. 2 Rotate injection sites. 3 Use the Z-track technique. 4 Avoid massaging the injection site
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in an air-conditioned room