Exam 3 Practice Questions
Which type of immunity will clients acquire through immunizations with live or killed vaccines? 1 Natural active immunity 2 Artificial active immunity 3 Natural passive immunity 4 Artificial passive immunity
2 Artificial active immunity Rationale: Artificial active immunity is acquired through immunization with live or killed vaccines. Natural active immunity is acquired when there is natural contact with antigens through a clinical infection. Natural passive immunity is acquired through the transfer of colostrum from mother to child. Artificial passive immunity is acquired by injecting serum from an immune human.
A client experiences expressive aphasia as a result of a brain attack (cerebrovascular accident, CVA). The client's spouse asks whether the client's speech will ever return. What is the best response by the nurse? 1 It should return in several months." 2 "You will have to ask the primary healthcare provider." 3 "It is hard to say how much improvement will occur." 4 "Unfortunately, your spouse will no longer be able to speak."
1 "It is hard to say how much improvement will occur.". Rationale: Recovery from aphasia [1] [2] is a continuous process; the amount of recovery cannot be predicted. The response "It should return in several months" gives false reassurance; it may take a year or longer or may never return. The response "You will have to ask the primary healthcare provider" abdicates the nurse's responsibility; the healthcare provider cannot predict return of function. Speech return is a continuous process; it may take a year or longer or may never return.
When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client? 1 Avoid leaning forward. 2 Hesitate between steps. 3 Rest when tremors are experienced. 4 Keep arms close to the center of gravity.
1 Avoid leaning forward. Rationale: The client with Parkinson disease often has a stooped posture [1] [2] [3] because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. The tremors of Parkinson disease occur at rest (resting tremors). The client must consciously attempt to maintain a natural arm swing for balance.
The healthcare provider is teaching a student about Parkinson disease (PD). Which of these statements best describes the brain abnormality characteristic of the disease? 1 Neurons in the substantia nigra begin to degenerate 2 Central nervous system neurons become demyelinated 3 Amyloid plaques are deposited in the brain 4 There is a progressive breakdown of the blood-brain barrier
1 Neurons in the substantia nigra begin to degenerate Rationale: As neurons in the substantia nigra begin to degenerate, they produce less dopamine, creating a deficiency of this neurotransmitter.
A patient diagnosed with dementia often becomes agitated and has angry outbursts. Which of the following interventions will the healthcare provider implement when caring for this patient? 1 Ensure the safety of the patient and staff 2 Utilize distraction when agitation occurs 3 Assist the patient to get involved in unit activities 4 Discuss the patient's behaviors in a rational manner 5 Ignore the patient when agitation occurs 6 Move the patient to a quiet environment
1 Ensure the safety of the patient and staff 2 Utilize distraction when agitation occurs 6 Move the patient to a quiet environment Rationale: Dementia interferes with the patient's ability to have a rational discussion about behaviors. Safety for all of the patients on the unit and for the staff is always the priority. Moving the patient to a quiet environment is aimed at decreasing stimulation. Distracting the patient at the first sign of agitation may also be helpful. Ignoring the patient can allow the agitation to escalate.
A specimen for arterial blood gases is obtained from a severely dehydrated 3-month-old infant with a history of diarrhea. The pH is 7.30, Pco 2 is 35 mm Hg, and HCO 3 - is 17 mEq/L (17 mmol/L). What complication does the nurse conclude has developed? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis
1 Metabolic acidosis Rationale: The blood pH indicates acidosis; the bicarbonate (HCO 3 -) level is further from the expected range than is the partial pressure of carbon dioxide (Pco 2), indicating a metabolic origin (losses from diarrhea), not a respiratory origin. The blood pH indicates acidosis, not alkalosis.
The healthcare provider is assessing an elderly patient who is disoriented to time and place. Which additional finding would support a diagnosis of delirium? 1 Sudden onset of symptoms 2 Attention is impaired 3 Slow and progressive course 4 Rambling and incoherent speech 5 Stable symptoms over time 6 Often linked to an identifiable cause
1 Sudden onset of symptoms 2 Attention is impaired 4 Rambling and incoherent speech 6 Often linked to an identifiable cause Rationale: Sudden onset and fluctuation of symptoms are key findings in delirium. Delirium is usually reversible because unlike dementia, delirium is usually due to a problem that can be identified and treated. Speech in a patient diagnosed with delirium is often rambling or incoherent, whereas speech in a patient diagnosed with dementia may be limited or aphasic. Attention in delirium is impaired, whereas attention in dementia is not impaired until late stages of the disease.
While caring for a client with a second-degree left ankle sprain, a nurse raises the injured part above heart level. What is the reason behind this nursing intervention? 1 To promote bone density 2 To prevent further edema 3 To reduce pain perception 4 To increase muscle strength
2 To prevent further edema Rationale: A client with a second-degree sprain may have a deeply torn ankle ligament with swelling and tenderness. Elevation of the injured lower limb above heart level helps mobilization of the excess fluid from the area and prevents further edema. Strengthening exercises help to build bone density and muscle strength and significantly reduce the risk of sprains and strains. Cryotherapy and adequate rest help to reduce pain by reducing the transmission and perception of pain impulses.
A patient diagnosed with Alzheimer disease (AD) is admitted to a long-term care facility. Which of the following assessment findings will the healthcare provider anticipate? 1 Apathy 2 Anhedonia 3 Amnesia 4 Agnosia 5 Aphasia
3 Amnesia 4 Agnosia 5 Aphasia Rationale: Brain structure changes caused by neurofibrillary tangles or amyloid plaques in the temporoparietal areas of the brain can cause impaired speech (aphasia), deficiencies in purposeful movements (apraxia), and problems comprehending visual or auditory stimuli (agnosia). Alterations in the hippocampus can cause short-term memory loss (amnesia).
What is the first activity of daily living (ADL) that the nurse should help teach a developmentally disabled 8-year-old child? 1 Dressing. 2 Toileting. 3 Self-feeding. 4 Combing hair.
3 Self-feeding. Rationale: Self-feeding is an early step in the progression of growth and developmental skills. All the steps for acquiring the skills needed to fulfill ADLs should progress in the same order as they do for a child who is not mentally challenged. The difference is the age when the skill is acquired and the difficulty in learning to acquire the skill. Dressing is a more advanced skill than self-feeding; it requires mastery of gross and fine motor skills and hand-eye coordination. Toileting is a more advanced skill than self-feeding; it requires control of the anal and urethral sphincters, readiness of psychophysiological factors, and motivation. Combing the hair is a more advanced skill than self-feeding. It requires control of gross and fine motor skills and muscle coordination.
The children of a patient diagnosed with Alzheimer disease (AD) tell the healthcare provider, "Our mother seems better during the day, but she gets very confused and agitated in the late afternoon and evenings." How should the healthcare provider document the patient's behavior? 1 Depression 2 Delirium 3 Sundowning 4 Psychosis
3 Sundowning Rationale: Patients diagnosed with AD may present with each of these problems, but one of them accurately represents this patient's behavior. The patient may also begin pacing or wandering, or the patient may become aggressive. This patient is experiencing sundowning or sundowner syndrome, a phenomenon prevalent in patients diagnosed with dementia. Sundowning may be associated with impaired circadian rhythms, environmental or social factors, and impaired cognition.
What should the nurse include when teaching a client with severe Parkinson disease about carbidopa-levodopa? 1 Multivitamins should be taken daily. 2 Alcohol consumption should be in moderation. 3 The medication should be taken with meals. 4 A high-protein diet should be followed.
3 The medication should be taken with meals. Rationale: Carbidopa-levodopa should be taken with meals to reduce the nausea and vomiting that commonly are caused by this drug. Multivitamins are contraindicated; vitamins may contain pyridoxine (vitamin B 6), which diminishes the effects of levodopa. Moderate amounts of alcohol will antagonize the drug's effects; a rare, occasional drink is not harmful. A high-protein diet is contraindicated. Sinemet contains levodopa, an amino acid that may increase blood urea nitrogen levels. Also, some proteins contain pyridoxine, which increases peripheral metabolism of levodopa, decreasing the amount of levodopa crossing the blood-brain barrier.
When reviewing the medical record of a patient diagnosed with Alzheimer disease (AD), the healthcare provider notes the patient is aphasic. Which behavior supports this finding? 1 Difficulty swallowing. 2 Unable to recognize objects. 3 Unable to speak . 4 Difficulty with motor function.
3 Unable to speak . Rationalize: The prefix "a" denotes "being without" something. "-phasia" refers to speech. A patient who is aphasic is unable to speak.
At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation? 1 Shutting the client's door during the night. 2 Applying a vest restraint when the client is in bed. 3 Leaving a dim light on in the client's room at night. 4 Administering the client's prescribed as-needed sedative medication.
3. Leaving a dim light on in the client's room at night . Rationale: A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.
When obtaining the health history of a patient diagnosed with Parkinson disease (PD), which of the following symptoms should the healthcare provider anticipate the patient to report? 1 "My eyes have become very sensitive to light." 2 "I used to be able to walk up the stairs without getting out of breath." 3 "I've been getting really severe headaches lately." 4 "Sometimes I feel like my feet are glued to the floor."
4 "Sometimes I feel like my feet are glued to the floor." Rationale: Patients with PD have difficulty initiating walking, and may feel like their feet are frozen to the floor. Fatigue is often experienced in Parkinson patients, but becoming short of breath when climbing is more likely to be reported by a patient with cardiovascular disease.
A patient diagnosed with dementia is prescribed a medication that inhibits acetylcholinesterase. Which of the following accurately explains how this medication benefits the patient? 1 Acetylcholine increases norepinephrine activity and decreases depression 2 Inhibition of acetylcholinesterase improves the patient's motor function 3 Decreased levels of acetylcholine will help decrease the patient's anxiety 4 Acetylcholine is needed for memory and problem solving
4 Acetylcholine is needed for memory and problem solving Rationale: Acetylcholinesterase inhibitors prevent the breakdown of acetylcholine in the brain. Differentiate the function of acetylcholine in the brain and acetylcholine in the peripheral nervous system. Because acetylcholine is involved in cognitive functions like memory and problem solving, increased levels of acetylcholine will improve these functions.
An older adult is being admitted to a nursing home with the diagnosis of dementia. The history reveals confusion, difficulty recognizing family members, and nighttime wandering. What should the nurse include in the client's plan of care? 1 Ordering a vest restraint for the client to be applied at night. 2 Obtaining a prescription for a sedative so the client will sleep better at night. 3 Requesting that the family provide a companion to stay with the client at night. 4 Assigning the client to a room near the nurses' station for closer supervision at night.
4 Assigning the client to a room near the nurses' station for closer supervision at night. Rationale: It is the nurse's responsibility to ensure the safety of clients; close supervision can help ensure that the client does not wander. Restraints should not be used without a primary healthcare provider's order; a restraint is too excessive an intervention to prevent wandering. The issue is not that the client does not sleep; the issue is that the client wanders. It is the responsibility of the facility, specifically the nurse, to meet the needs of and ensure the safety of clients.
A nurse is caring for an older adult with a history of recent memory loss. Which action should the nurse take? 1 Instruct the client to move slowly when changing positions. 2 Remind the client to look where places feet while walking. 3 Adjust the daily schedule to accommodate sleep pattern. 4 Employ electronic devices that provide alerts.
4 Employ electronic devices that provide alerts Rationale: Providing electronic devices that give alerts can help an older adult who has developed recent memory loss. Adjusting the daily schedule can aid older adults who have changes in their sleep pattern. Instructing the client to move slowly when changing positions can prevent dizziness and falls caused by orthostatic blood pressure changes or altered balance/coordination. Reminding the client to check where feet are placed can help older adults with a decreased sensory perception of touch.
When planning care for a patient diagnosed with Alzheimer disease (AD), which of these interventions is most therapeutic? 1 Speaking in a loud, clear voice when talking to the patient 2 Providing immediate feedback by correcting errors in the patient's speech 3 Giving the patient several directions at a time to improve memory 4 Encouraging both verbal and nonverbal communication
4 Encouraging both verbal and nonverbal communication Rationale: The healthcare provider will plan interventions aimed at reducing stimulation and decreasing the patient's frustration. Speaking clearly and calmly is effective, but increasing the volume of the voice is not effective and can increase the patient's anxiety. As the ability to communicate verbally declines, nonverbal communication may become more prominent. Encouraging both can facilitate communication and decrease frustration.
A patient diagnosed with delirium sees the intravenous (IV) tubing and believes it to be a snake. How should the healthcare provider document this behavior? 1 Hallucination 2 Delusion 3 Confusion 4 Illusion
4 Illusion Rationale: The patient is experiencing an illusion, which is the misinterpretation of a real stimulus. A hallucination is a false sensory perception not associated with a real stimulus. A delusion is a false personal belief that is maintained in spite of evidence to the contrary. A patient who is confused would not believe the IV tubing is a snake
Carbidopa/Levodopa is prescribed for a client with Parkinson's Disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? 1 Pruritus 2 Tachycardia 3 Hypertension 4 Impaired voluntary movements
4 Impaired voluntary movements Rationale: Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.
A patient diagnosed with Parkinson disease (PD) is prescribed levodopa. The medication therapy can be considered effective when the healthcare provider assesses improvement in which of the following? 1 Hearing 2 Visual acuity 3 Appetite 4 Urinary frequency
4 Urinary frequency
A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? 1 Urinary retention 2 Gastric hyperacidity 3 Rebound tenderness 4 Increased lower bowel motility
3 Rebound tenderness Rationale: Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute lower right quadrant pain. Hyperacidity causes epigastric, not lower right quadrant pain. There generally is decreased bowel motility distal to an inflamed appendix.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis
3 Respiratory acidosis. Rationale: The pH indicates acidosis [1] [2]; the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.
A patient diagnosed with Alzheimer disease (AD) is demonstrating signs of impaired reasoning. The healthcare provider suspects an alteration in which area of the brain? 1 Hippocampus 2 Amygdala 3 Frontal Lobe 4 Occipital Lobe
3 Frontal Lobe Rationale: Frontal lobe function would be altered if the patient is demonstrating signs of impaired reasoning.
Two days after admission to the detoxification program, a client with a long history of alcohol abuse tells the nurse, "I don't know why I came here." What is the most therapeutic response by the nurse? 1 "You feel that you don't need this program?" 2 "You realize that you are trying to avoid your problem?" 3 "I thought that you admitted yourself into the program." 4 "Don't you remember why you decided to come here in the first place?"
1 "You feel that you don't need this program?" Rationale: The statement "You feel that you don't need this program?" identifies the feeling of ambivalence associated with admitting that a problem with alcohol exists; this occurs early in treatment. Asking whether the client realizes that there is a problem, remarking that the client self-admitted into the program, and asking whether the client remembers the reason for deciding to come in the first place puts the client on the defensive and interferes with communication.
A patient with a history of depression who experiences memory lapses and word finding difficulty is diagnosed with pseudodementia. Which of these represents a characteristic of pseudodementia? 1 Cognitive impairments are reversible 2 Lewy bodies form within the brain tissue 3 Psychosis is a prominent feature 4 Eventually evolves into Alzheimer disease
1 Cognitive impairments are reversible Rationale: Pseudodementia usually has an abrupt onset. The major symptoms are related to cognitive impairments. Pseudodementia refers to reversible cognitive impairments seen in patients who have a history of depression.
The healthcare provider is caring for a patient diagnosed with a mild cognitive impairment. Which of these would be the most effective intervention for this patient? 1 Frequent reorientation 2 Relaxation therapy 3 Behavior modification 4 Application of soft restraints
1 Frequent reorientation Rationale: Restraints can increase agitation and should not be used unless absolutely necessary and only when certain criteria are met. Behavior modification is an intervention aimed at changing undesirable behaviors. Frequent reorientation is the most effective intervention for a patient diagnosed with mild cognitive impairment.
During the administration of a Mini-Mental Status Exam (MMSE), the healthcare provider asks the patient to copy a simple geometric shape. This part of the exam tests which of the following mental functions? 1 Visual comprehension and praxis 2 Attention and calculation abilities 3 Orientation and short-term memory 4 Hearing and language skills
1 Visual comprehension and praxis Rationale: The MMSE screens for cognitive loss by testing the patient's orientation, attention, calculation, comprehension, recall, language, and motor skills. The healthcare provider will observe how well the patient copies the shape.Copying the shape successfully demonstrates visual comprehension and the ability to plan and execute coordinated movement (praxis).
The nurse is teaching a group of students about the manifestation of alkalosis in the central nervous system. Which statements by a student nurse are accurate? Select all that apply. 1 The client's Chvostek sign would be negative." 2 "The client's Trousseau sign would be positive." 3 "The client would be suffering from paresthesias." 4 "The client would show signs of anxiety and irritability." 5 "The client's central nervous system should have a decrease activity in case alkalosis."
2 "The client's Trousseau sign would be positive." 3 "The client would be suffering from paresthesias." 4 "The client would show signs of anxiety and irritability." Rationale: If clients suffer from the alkalosis, the manifestation in the nervous system would involve paresthesias. The client will also have a positive Trousseau sign and have anxiety and irritability. The Chvostek sign would also be positive, not negative. The client would show signs of anxiety and irritability. The central nervous system should have increased activity with alkalosis, not decreased.
The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem? 1 A long history of inadequate nutrition 2 Disruptions in cerebral blood flow, resulting in thrombi or emboli. 3 A delayed response to severe emotional trauma in early adulthood. 4 Anatomical changes in the brain that produce acute, transient symptoms.
2 Disruptions in cerebral blood flow, resulting in thrombi or emboli. Rationale: Vascular dementia results from the sudden closure of the lumen of arterioles, causing infarction of the brain tissue in the affected area. Inadequate nutrition may be one of the factors that bring about a general decline of health; however, there is no direct evidence that avitaminosis can cause primary degenerative dementia. Severe emotional trauma may contribute to primary degenerative dementia but does not necessarily cause it. Neural degeneration leads to permanent, not transient, changes.
A patient is admitted to the mental health unit with a diagnosis of vascular dementia. Which of the following describes the brain alteration involved in this disorder? 1 Formation of beta-amyloid plaques 2 Hypoxic damage to brain tissue 3 Enlargement of the ventricles 4 Decreased choline acetyltransferase
2 Hypoxic damage to brain tissue Rationale: Patients diagnosed with vascular dementia will have additional physical health problems that are associated with the dementia. Vascular dementia does not involve the accumulation of abnormal proteins within the brain. Vascular dementia is characterized by a progressive worsening of cognitive function due to vascular disease within the brain. Decreased blood flow and tissue hypoxia is often secondary to cerebrovascular disease.
During an 8-hour shift a client drinks two 6-ounce (180 mL) cups of tea and vomits 125 mL of fluid. Intravenous fluids absorbed equaled the urinary output. What is the client's fluid balance during this 8-hour period? Record your answer using a whole number. ___ mL
235mL Rationale: 235 mL is the correct calculation. The client's intake was 360 mL (12 oz × 30 mL = 360 mL) and the loss was 125 mL of fluid; 360 mL - 125 mL = 235 mL.
A nurse is caring for a client who has been admitted to a healthcare facility for the treatment of sinus disorders. The nurse discovers that the client is a cocaine addict. What task followed by the nurse is the best way to deal with the situation? 1 Teach the client about safe medication storage and the danger of polypharmacy. 2 Educate the client about his or her correct body mechanics and promote stress management. 3 Assess the client's drug intake and ensure that the individual does not leave the healthcare facility. 4 Assist with adequate personal hygiene, nutrition, and hydration and provide emotional support to the family.
3 Assess the client's drug intake and ensure that the individual does not leave the healthcare facility. Rationale: When dealing with a client with substance abuse issues, the nurse should assess the client's drug intake in terms of the amount, frequency, and type of use to obtain useful information. Clients with substance abuse problems tend to avoid healthcare facilities for fear of judgmental attitudes and worries over being arrested by the police. In this case, the nurse should ensure that the client does not prematurely leave the facility. When dealing with a client with medication use and abuse issues, the nurse should provide proper education about safe medication storage and the danger of polypharmacy. When dealing with a client with arthritis, the nurse should educate the client about correct body mechanics and should also promote stress management. When dealing with clients in a confused state, the nurse should assist him or her with adequate personal hygiene, nutrition, and hydration and provide emotional support to the family.
A nurse is providing preoperative teaching to the parents of a toddler who is to undergo myringotomy. The nurse explains that the type of infection most common in children that are prone to otitis media is what? 1 Viral 2 Fungal 3 Bacterial 4 Rickettsial
3 Bacterial Rationale: Haemophilus influenzae and Streptococcus pneumoniae, both bacteria, are the most frequent causes of otitis media. If an ear infection develops, the parents should contact their healthcare provider immediately so an antibiotic may be prescribed. Otitis media is not caused by viral, fungal, or rickettsial organisms.
The nurse observes that 12 hours after birth the neonate is hyperactive and jittery, sneezes frequently, has a high-pitched cry, and is having difficulty suckling. Further assessment reveals increased deep tendon reflexes and a diminished Moro reflex. What problem does the nurse suspect? 1 Cerebral palsy 2 Neonatal syphilis 3 Opioid drug withdrawal 4 Fetal alcohol syndrome
3 Opioid drug withdrawal Rationale: These signs are indicative of withdrawal from an opioid with typical changes occurring in the central nervous system; the newborn should be monitored during the first 24 to 48 hours. The signs of cerebral palsy usually manifest later in infancy. The signs of syphilis are a low-grade fever and a copious serosanguineous discharge from the nose. The signs of fetal alcohol syndrome are growth deficiencies in length, weight, and head circumference, plus distinctive facies.
An older client with the diagnosis of dementia of the Alzheimer type is admitted to a long-term care facility. What should the nurse keep in mind regarding confusion when planning care for this client? 1 Confusion occurs with a transfer to new surroundings. 2 Confusion will be unchanged despite reality orientation. 3 Confusion is a common finding and is expected with aging. 4 Confusion results from brain changes that make interventions futile.
1 Confusion occurs with a transfer to new surroundings. Rationale: A change in environment and introduction of unfamiliar stimuli precipitate confusion in clients with dementia-type disorders; with appropriate intervention, including frequent reorientation, confusion can be reduced. Reality orientation can reduce confusion when these clients are confronted with unfamiliar surroundings. The assertions that reality orientation is ineffective, that confusion is an expected finding in aging, and that brain changes in dementia make interventions futile are all untrue.
A client is admitted with cellulitis of the left leg and a temperature of 103° F (39.4° C). The primary healthcare provider prescribes intravenous (IV) antibiotics. Which action is the priority before administering the antibiotics? 1 Determine the client's allergies. 2 Apply a warm, moist dressing over the cellulitis. 3 Measure the amount of swelling in the client's left leg. 4 Obtain the results of the culture and sensitivity tests
1 Determine the client's allergies. Rationale: Allergies are important. Drug hypersensitivity and anaphylaxis are most common with antimicrobial agents. Applying a warm, moist dressing over the area is a dependent function; it is not crucial to starting antibiotic therapy. Measuring the amount of swelling in the client's leg is an important assessment, but it is not crucial to starting antibiotic therapy. Withholding treatment until culture results are available may extend the infection.
The healthcare provider is assessing a patient with a diagnosis of Parkinson disease (PD). Which of the following assessments will the healthcare provider anticipate? 1 Pill-rolling tremor when the hand is at rest 2 An absence of stereognosis 3 Deep tendon reflexes graded as 1 4 Twisting and protruding movements of the tongue
1 Pill-rolling tremor when the hand is at rest Rationale: A "pill-rolling" tremor typical of PD is described as is a rest tremor, which means it is most noticeable when the body part is not engaged in purposeful activities. Tremors in other conditions, such as multiple sclerosis, are typically action tremors, where the tremor happens when the affected limb is being used. Twisting and protruding movements of the tongue are characteristic of tardive dyskinesia, which is a movement disorder associated with prolonged use of dopamine receptor blocking agents. Stereognosis, the ability to recognize a small, familiar object when placed in the patient's hand, may be absent in patients with disease in the parietal lobe, where sensation is interpreted. A reflex graded as 111 is considered hypoactive and is not an expected finding in a patient who has PD.
A woman who abused drugs during pregnancy gave birth to a drug-dependent neonate. Which nursing interventions would be beneficial to the neonate? Select all that apply. 1 To administer smaller doses of the dependent drug 2 To administer pain relievers during delivery 3 To monitor the neonate carefully and closely 4 To educate the mother about the risks of drug abuse 5 To stop the drug on which the neonate is dependent immediately to avoid dependence
1 To administer smaller doses of the dependent drug 3 To monitor the neonate carefully and closely 4 To educate the mother about the risks of drug abuse Rationale: A neonate should be weaned from drug dependence by administering smaller doses of the drugs to which he or she is dependent. These doses should be tapered to avoid withdrawal syndrome. The neonate should be monitored carefully and closely so that the medical team can quickly react to any issues that may arise. The mother should be educated about the risk of drug abuse to prevent further exposure to the drug. Pain relievers administered during delivery may cause respiratory depression. If the dependent drug is stopped immediately, the neonate may develop withdrawal syndromes.
The nurse is providing care to an infant diagnosed with Down syndrome. Which parental statement related to the infant's growth indicates the need for further education? 1 "My baby will have growth deficiencies during infancy." 2 "My child will have accelerated growth during adolescence." 3 "My child will most likely be overweight by 3 years of age." 4 "My baby will have reduced growth in both height and weight."
2 "My child will have accelerated growth during adolescence." Rationale: Children diagnosed with Down syndrome will often have growth deficiencies. These deficiencies are most pronounced during adolescence and infancy. Because weight gain is more rapid than growth in stature, many children with Down syndrome are overweight by 3 years of age. Overall reduced growth is noted for both height and weight.
A patient who has been prescribed the antiparkinsonian medication carbidopa/levodopa, asks the healthcare provider, "Why am I getting these two medications?" How should the healthcare provider respond? 1 "You will experience fewer side effects when you take both medications together." 2 "The carbidopa prevents the breakdown of the levodopa." 3 "This drug combination is composed of two types of the same medication." 4 "The levodopa turns the carbidopa into dopamine when it reaches the brain."
2 "The carbidopa prevents the breakdown of the levodopa." Rationale: Carbidopa prevents the breakdown (decarboxylation) of levodopa in the intestine and peripheral tissues do more levodopa can travel to the brain, cross the blood brain barrier, where it is converted into.
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.
2 Give prescribed drugs to promote bronchiolar dilation. Rationale: Asthma involves spasms of the bronchi and bronchioles as well as increased production of mucus; this decreases the size of the lumina, interfering with inhalation and exhalation. Bronchiolar dilation will reduce airway resistance and improve the client's breathing. Although identifying and addressing a client's emotional state is important, maintaining airway and breathing are the priority. In addition, emotional stress is only one of many precipitating factors, such as allergens, temperature changes, odors, and chemicals. Although recent studies indicate a genetic correlation along with other factors that may predispose a person to develop asthma, exploring this issue is not the priority. Use of an incentive spirometer is not helpful because of mucosal edema, bronchoconstriction, and secretions, all of which cause airway obstruction.
An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? Select all that apply. 1 Limiting fluid intake 2 Instilling saline nose drops 3 Maintaining contact precautions 4 Suctioning mucus with a bulb syringe 5 Administering warm humidified oxygen
2 Instilling saline nose drops 3 Maintaining contact precautions 4 Suctioning mucus with a bulb syringe Rationale: Saline nose drops help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSV produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss. These infants have difficulty nursing and often vomit their feedings. If measures such as suctioning before feeding and instilling saline nose drops are ineffective, intravenous fluid replacement is instituted. The humidified oxygen should be cool. It relieves the dyspnea and hypoxia that is prevalent in infants with RSV.
Which of the following, if assessed in a patient, will the healthcare provider identify as a risk factor for the development of delirium? 1 Decreased social interactions 2 Organ failure 3 Administration of opioids 4 Decreased physical activity 5 Sleep deprivation 6 Infections
2 Organ failure 3 Administration of opioids 5 Sleep deprivation 6 Infections Rationale: Sleep deprivation (common in hospitalized patients), organ failure, infections, and numerous drugs can put a patient at risk for delirium. Decreased social interaction can exacerbate delirium but will not cause delirium. Here's handy mnemonic to remember general risk factors for delirium: D = Dementia, E = Electrolyte disorders, L = Liver, lung, heart, kidney, brain, I = Infection, R = Rx (medications), I = Injury, pain, stress, U = Unfamiliar environment, M = Metabolic
A person who is hospitalized for alcoholism becomes boisterous and belligerent and verbally threatens the nurse. What is the most appropriate response by the nurse? 1 Placing the client in restraints 2 Sedating and placing the client in a controlled environment 3 Encouraging the client to play table tennis with another client 4 Setting firm limits on the client's behavior and enforcing adherence to them
2 Sedating and placing the client in a controlled environment Rationale: The client is out of control and therefore dangerous to self and others. Safety requires sedation and a controlled environment. Restraining a disturbed, belligerent client can result in injury, because restraints generally increase anxiety and acting out. The client's attention span is too short for table tennis. Any measures directed at verbal or physical correction of the client's behavior will be ineffective.
A nurse teaches a client scheduled for a tracheostomy about ways to prevent aspiration during swallowing. Which statement of the client indicates the need for further teaching? 1 "I should eat smaller and more frequent meals." 2 "I should avoid eating meals when I am fatigued." 3 "I should drink more water and other thin liquids." 4 "I should keep emergency suctioning equipment close at hand."
3 "I should drink more water and other thin liquids." Rationale: A client with a tracheotomy is at risk of aspirating food, gastric contents, or oral secretions into the lungs. Water and other thin liquid consumption should be avoided because these substances have higher chances of entering the lungs. Thicker liquids are advised because they are easier to swallow. Consuming smaller and more frequent meals may help to ease swallowing and prevent aspiration. Consuming meals in a fatigued condition may lead to aspiration due to inadequate efforts of swallowing. Placing emergency suction equipment close at hand may help to eliminate sudden aspiration.
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? 1 Red blood cell count 2 Sputum culture 3 Arterial blood gas 4 Total hemoglobin
3 Arterial blood gas Rationale: Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.
A patient who is diagnosed with Parkinson disease (PD) states, "I can't tie my shoelaces anymore." The healthcare provider recognizes that this patient's problem is due to a deficiency in which of these neurotransmitters? 1 Glutamate 2 Norepinephrine 3 Dopamine 4 Serotonin
3 Dopamine Rationale: Dopamine helps our brains control movement and coordination. The cells in the brain that make dopamine slowly die in patients who have PD, making it increasingly difficult to control muscles for movement, including fine motor movement needed to tie one's shoelaces.
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.
3 Encourage the client to speak while allowing time to respond. Rationale: In addition to the extent of injury, a factor in relearning speech is the client's motivation and effort. The more the client attempts to talk, the more likely speech will progress to its optimum level; relearning is a slow process. Clients with aphasia are not deaf. Although the nurse should instruct the family to approve and support the client's efforts to communicate, this support should be for the effort, not for correct communication. Telling the client to use the correct words when speaking will create frustration and may anger the client.
A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. The infant's breathing is deep, rapid, and unlabored. The mother states that the infant has had liquid stools and no obvious urine output. What problem does the nurse conclude that the infant is experiencing? 1 Kidney failure 2 Mild dehydration 3 Metabolic acidosis 4 Respiratory alkalosis
3 Metabolic acidosis Rationale: Metabolic acidosis occurs with loss of alkaline fluid through diarrhea and is manifested by lethargy and Kussmaul breathing; all of the assessments indicate severe dehydration. The infant has not urinated because excessive amounts of fluid have been lost in the loose stools; this indicates that the kidneys are functioning by compensating for the fluid loss. All data indicate a severe, not mild, fluid volume deficiency. Respiratory alkalosis is caused by an excessive loss of carbon dioxide, not diarrhea.
When planning care for a patient diagnosed with Parkinson disease (PD), which of these patient outcomes should receive priority in the patient's plan of care? 1 Taking a vitamin supplement each day 2 Taking a daily walk around the neighborhood 3 Toileting and bathing independently 4 Working on a favorite hobby
3 Toileting and bathing independently Rationale: Being able to perform such tasks as toileting and bathing is important in maintaining some degree of independence and quality of life, so this is the priority outcome.
The nurse is instructing a client with Parkinson's Disease about preventing falls. Which client statement reflects a need for further teaching? 1 "I can sit down to put on my pants and shoes" 2 "I try to exercise every day and rest when I'm tired" 3 "My son removed all loose rugs from my bedroom" 4 "I don't need to use my walker to get to the bathroom"
4 "I don't need to use my walker to get to the bathroom" Rationale: The client with Parkinson's Disease should be instructed regarding safety measures in the home. The client should use her or his walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to prevent falling.
Which complications does the nurse anticipate in the client who has blue-colored nail beds? 1 Thrombocytopenia 2 Polycythemia vera 3 Methemoglobinemia 4 Cardiopulmonary disease
4 Cardiopulmonary disease Rationale: A bluish-color to the nail beds is due to an increase in deoxygenated blood that may be due to cardiopulmonary disease. When there is bleeding from the vessels into the tissues, small blue-colored spots are formed (petechiae), which may be due to thrombocytopenia (decreased numbers of platelets). Polycythemia vera is characterized by brown spots on the skin caused by increased melanin production. Methemoglobinemia is a complication in which the mucous membranes appear blue in color due to increased deoxygenated blood in the body.
During an interview with a patient with a diagnosis of Parkinson disease (PD), which of the following speech patterns will the healthcare provider anticipate? 1 Pressured and hurried 2 Clear and rhythmic 3 Bubbly and spirited 4 Slow, slurred, and monotone
4 Slow, slurred, and monotone Rationale: The neuromuscular effects of PD often affect vocal articulation, so the healthcare provider would expect slowed, often monotone speaking patterns and difficulty articulating clearly. Pressured and hurried speech is characteristic of patients who have hyperthyroidism. Clear and rhythmic is fluency is an expected finding in a patient with normal speech patterns.
