Lewis Final Questions

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?

"The obstructing plaque is surgically removed from inside an artery in the neck."

Which of these nursing actions for a patient with Guillain-Barré syndrome is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)?

Passive range of motion to extremities q4hr

Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first?

Patient who has had 10 liquid stools in the last 24 hours

The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?

Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

After change-of-shift report on the neurology unit, which patient will the nurse assess first?

Patient with botulism who is drooling and experiencing difficulty swallowing

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?

Patient's ability to follow a complex medication regimen

Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke?

Place needed objects on the patient's left side.

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?

Positioning the patient's left leg when turning the patient

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?

Prevention of HIV transmission between sexual partners

Which action will the nurse take when caring for a patient who develops tetanus from injectable substance use

Provide a quiet environment.

The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on patient information shown in the accompanying figure, which action should the nurse take?

Provide support to the spouse caregiver.

A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?

Remind the patient about the need to return for retesting to verify the results.

A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, "I want to be transferred to a hospital where the nurses know what they are doing." Which action by the nurse is appropriate?

Request that the patient provide input for the plan of care.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient?

Risk for aspiration.

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

Start a labetalol drip to keep BP less than 140/90 mm Hg.

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?

Stock the patient's room with the necessary personal protective equipment.

A patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond?

Teach the family that emotional outbursts are common after strokes.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

The patient has atrial fibrillation and takes warfarin (Coumadin).

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?

The patient has difficulty speaking.

A patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action?

The patient has new-onset weakness of both legs.

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action?

The patient is continuously drooling saliva.

The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?

The patient reports missing some doses of zidovudine (AZT).

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?

The patient reports that symptoms began with a severe headache.

A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?

The patient will maintain intact perineal skin.

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

The patient's blood pressure (BP) is 90/50 mm Hg.

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address?

The patient's usual blood pressure (BP) is 170/94 mm Hg.

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about

oral low-dose aspirin therapy.

When the nurse is developing a rehabilitation plan for a 30-yr-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to

push a manual wheelchair on a flat surface.

A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. The initial intervention by the nurse should be to

push upward on the epigastric area as the patient coughs.

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse is to

respect the patient's feelings and arrange for privacy at mealtimes.

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis

to call the health care provider if stools are tarry.

The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient about

triggers leading to facial discomfort.

During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have

visual deficits.

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?

"Call the doctor if you experience pain or develop herpes lesions near the ear."

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate?

"Can you tell me more about the thoughts that you are having?"

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?

"Consider participating in a needle-exchange program."

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?

"The patient has developed acquired immunodeficiency syndrome (AIDS)."

The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient?

"You will need to be retested in 2 weeks."

After receiving change-of-shift report on the following four patients, which patient should the nurse see first?

A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed.

A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol?

Administer oxygen to keep O2 saturation >95%. Use National Institute of Health Stroke Scale to assess patient. Obtain CT scan without contrast. Infuse tissue plasminogen activator (tPA).

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?

Administer the prescribed short-acting insulin.

Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs?

Age

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)?

Antibiotics may sometimes be prescribed to prevent infection. Continue taking antibiotics until all of the prescription is gone. Hand washing is effective in preventing many viral and bacterial infections.

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care?

Apply intermittent pneumatic compression stockings.

A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate?

Ask questions that the patient can answer with "yes" or "no."

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the patient?

Aspirin

Which action will the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia?

Assess fluid and dietary intake.

A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first?

Assess the blood pressure (BP).

Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Assessment of respiratory rate and effort

To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?

Assist in planning a prescribed bowel program.

A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take?

Assist the patient into a chair.

Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program?

Assist the patient onto the bedside commode every 2 hours.

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care?

Assist the patient to eat with the right hand.

Which action will the nurse include in the plan of care for a patient who has a cauda equina spinal cord injury?

Catheterize patient every 3 to 4 hours.

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?

Check the patient's class schedule to help decide when the drugs should be taken.

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

Check the respiratory rate and effort.

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?

Computed tomography (CT) scan.

A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?

Continue to use contraception while taking this medication.

Which finding in a patient with a spinal cord tumor requires an immediate report to the health care provider?

Decreased ability to move the legs

What concern should the nurse anticipate for a patient who had a right hemisphere stroke?

Denial of deficits and impulsiveness.

A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?

Difficulty comprehending instructions

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient?

Discuss a change in antiretroviral therapy.

Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/μL and an undetectable viral load. What is the priority nursing intervention at this time?

Encourage adequate nutrition, exercise, and sleep.

A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by the health care provider will the nurse question?

Encourage oral fluids to 3 L/day.

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take?

Explain that the aspirin is ordered to decrease stroke risk.

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take?

Explain to the patient that this is an expected finding.

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea (select all that apply)?

Gown Gloves

The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)?

Hepatitis B vaccine Pneumococcal vaccine Influenza virus vaccine

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock?

Hypotension and warm extremities

In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department?

Immobilize the patient's head, neck, and spine. Administer O2 using a nonrebreather mask. Monitor cardiac rhythm and blood pressure. Infuse normal saline at 150 mL/hr. Transfer the patient to radiology for spinal computed tomography (CT).

Which patient assessment will help the nurse identify potential complications of trigeminal neuralgia?

Inspect the oral mucosa and teeth.

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care?

Instruct the patient how to self-catheterize.

An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching?

Many drugs interact with antiretroviral medications.

A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?

Most infants born to HIV-positive mothers are not infected with the virus.

A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which initial response by the nurse is best?

Multiple options are available to maintain sexuality after spinal cord injury.

Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown?

Needle stick with a needle and syringe used for a venipuncture

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time?

Oral saquinavir (Invirase)

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient?

Tissue plasminogen activator (tPa) infusion.

When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)?

Urinary catheter care Continuous cardiac monitoring Administration of H2 receptor blockers Maintenance of a warm room temperature

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?

Viral load testing

Before administering botulinum antitoxin to a patient in the emergency department, it is most important for the nurse to

administer an intradermal test dose.

A construction worker arrives at an urgent care center with a deep puncture wound from a rusty nail. The patient reports having had a tetanus booster 6 years ago. The nurse will anticipate

administration of the tetanus-diphtheria (Td) booster.

When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia, the nurse will

ask the patient about social activities with family and friends.

A patient is hospitalized with new onset of Guillain-Barré syndrome. The most essential assessment for the nurse to complete is

observing respiratory rate and effort.

A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. The appropriate nursing action at this phase of rehabilitation is to

develop a plan to increase the patient's independence in consultation with the patient and the spouse.

The nurse will explain to the patient who has a T2 spinal cord transection injury that

function of both arms should be retained.

A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. The nurse will anticipate teaching the patient about

insertion of a nasogastric (NG) feeding tube.