Med Surg Exam 3 Practice Questions Part 4
38. Which statement by a client with a seizure disorder who has been prescribed topiramate indicates the client has understood the nurse's instruction about this drug? "I will take the medicine before going to bed." "I will drink six to eight glasses of water a day." "I will eat plenty of fresh fruits." "I will take the medicine with a meal or snack "
"I will drink six to eight glasses of water a day."
90. After teaching a client about myasthenia gravis, the nurse would judge that the client has formed a realistic concept of the disease and the treatment plan when the client makes which statement? "I'll live longer, but ultimately the disease will cause death." "My symptoms will be controlled, and eventually I will be cured." "I'll be able to control the disease and enjoy a healthy lifestyle." "I won't be so tired, but I can expect occasional periods of muscle weakness."
"I'll be able to control the disease and enjoy a healthy lifestyle."
45. The nurse is teaching a client about taking prophylactic warfarin sodium. Which statement indicates that the client understands how to take the drug? Select all that apply. "The drug's action peaks in 2 hours." "Maximum dosage is not achieved until 3 to 4 days after starting the medication." "Effects of the drug continue for 4 to 5 days after discontinuing the medication." "Protamine sulfate is the antidote for warfarin." "I should have my blood levels tested periodically."
"Maximum dosage is not achieved until 3 to 4 days after starting the medication." "Effects of the drug continue for 4 to 5 days after discontinuing the medication." "I should have my blood levels tested periodically."
81. The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses' notes of the medical record for this client assessment? "Has an intention tremor of the right hand." "Right-hand tremor worsens with purposeful acts." "Needs assistance with dressing and eating due to severe trembling and clumsiness." "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."
"Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."
28. It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. What should the nurse tell the client to do to prepare for this test? "You must shampoo your hair tonight to remove all oil and dirt." "You may drink fluids until midnight, but after that, drink nothing until the scan is completed." "You will have some hair shaved to attach the small electrode to your scalp." "You will need to hold your head very still during the examination."
"You will need to hold your head very still during the examination."
25. A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client? "I'll get your family." "Can you tell me your name and where you live?" "I'll bet you are a little confused right now." "You're in the hospital. You were in an accident and unconscious."
"You're in the hospital. You were in an accident and unconscious."
57. The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Select all that apply. 1. maintaining an upright position while eating 2. restricting the diet to liquids until swallowing improves 3. introducing foods on the unaffected side of the mouth 4. keeping distractions to a minimum 5. cutting food into large pieces of finger food
1. maintaining an upright position while eating 3. introducing foods on the unaffected side of the mouth 4. keeping distractions to a minimum
44. A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?
15
84. The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. What information should the nurse include in the teaching plan? 1. "You'll need to accept the necessity for a quiet and inactive lifestyle." 2. "Keep active, use stress reduction strategies, and avoid fatigue." 3. "Follow good health habits to change the course of the disease." 4. "Practice using the mechanical aids that vou'll need when future disabilities arise."
2. "Keep active, use stress reduction strategies, and avoid fatigue."
67. The nurse observes that when a client with Parkinson's disease unbuttons her shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? 1. The tremors are probably psychological and can be controlled at will. 2. The tremors sometimes disappear with purposeful and voluntary movements. 3. The tremors disappear when the client's attention is diverted by some activity. 4. There is no explanation for the observation; it is a chance occurrence.
2. The tremors sometimes disappear with purposeful and voluntary movements.
112. When a nurse is assessing a client for pain, what finding is most significant? The client: 1. protects a specific area of the body. 2. tells the nurse about experiencing pain. 3. has a change in vital signs. 4. appears to be uncomfortable.
2. tells the nurse about experiencing pain.
68. At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? 1. early in the morning, when the client's energy level is high 2. to coincide with the peak action of drug therapy 3. immediately after a rest period 4. when family members will be available
2. to coincide with the peak action of drug therapy
26. The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used. Maintain a patent airway. Record the seizure activity observed. Ease the client to the floor. Obtain vital signs.
3, 1, 4, 2
93. The nurse is caring for a client who is unconscious following an attempted suicide by drug overdose. When speaking with the client's distraught wife, what should the nurse do first? 1. Explain that because the client was found on hospital property, he was probably asking for help and did not intentionally overdose. 2. Ask the wife if she would like to speak to a member of the clergy. 3. Encourage the wife to express her feelings and concerns, and listen carefully. 4. Allow the wife to help care for the client by rubbing his back when he is turned.
3. Encourage the wife to express her feelings and concerns, and listen carefully.
43. Following a stroke, a client has dysphagia and left-sided facial paralysis. Which feeding technique will be most helpful at this time? 1. Encourage sipping diluted liquid meal supplements from a straw. 2. Position the client with the bed at a 30-degree angle. 3. Offer solid foods from the unaffected side of the mouth. 4. Feed the client a soft diet from a spoon into the left side of the mouth.
3. Offer solid foods from the unaffected side of the mouth.
30. The client is scheduled to receive phenytoin through a nasogastric tube and has a tube-feeding supplement running continuously. The head of the bed is elevated to 30 degrees. Prior to administering the medication, what should the nurse do? 1. Elevate the head of the bed to 60 degrees. 2. Draw blood to determine the phenytoin level after giving the morning dose in order to determine if the client has toxic blood level. 3. Stop the tube feeding 1 hour before giving phenytoin, and hold tube feeding for 1 hour after giving the medication. 4. Flush the NGT with 150 mL of water before and after giving the phenytoin.
3. Stop the tube feeding 1 hour before giving phenytoin, and hold tube feeding for 1 hour after giving the medication.
50. A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bpm, respirations are 22 breaths/min, bilateral rhonchi are auscultated, SpO, is 94%, blood pressure is 144/88 mm He, and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? All options must be used. Suction the airway. Hyperoxygenate. Suction the mouth. Provide sedation.
4, 2, 1, 3
7. A client has delirium following a head iniury. The client is disoriented and agitated. In which order from first to last should the nurse initiate care for this client? All options must be used. Request a prescription for haloperidol. Maintain a quiet environment. Assure the client's safety. Approach the client using short sentences.
4, 3, 2, 1
120. The nurse ascertains that there is a discrepancy in the records of use of a controlled substance for a client who is taking large doses of narcotic pain medication. What should the nurse do next? 1. Notify the police. 2. Contact the hospital's administration or legal department. 3. Notify the pharmacy technician who delivered the controlled substance. 4. Notify the nursing supervisor of the clinical unit.
4. Notify the nursing supervisor of the clinical unit.
21. The nurse is assessing a client with a head injury for decerebrate posturing. Which position indicates the client has decerebrate posturing? 1. internal rotation and adduction of arms with flexion of elbows, wrists, and fingers 2. back hunched over and rigid flexion of all four extremities with supination of arms and plantar flexion of feet 3. supination of arms and dorsiflexion of the feet 4. back arched and rigid extension of all four extremities
4. back arched and rigid extension of all four extremities
89. The nurse is discussing discharge instructions with a client with myasthenia gravis who is taking pyridostigmine. What should the nurse instruct the client to do? Administer artificial tears. Avoid contact with crowds. Take pyridostigmine in the afternoon. Decrease protein in the diet.
Administer artificial tears.
33. Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures? Maintain the client on bed rest. Administer a sedative as prescribed. Close the door to the room to minimize stimulation. Administer carbamazepine 200 mg PO, twice per day.
Administer carbamazepine 200 mg PO, twice per day.
32. What is the priority nursing intervention in the postictal phase of a seizure? Reorient the client to time, person, and place. Determine the client's level of sleepiness. Assess the client's breathing pattern. Position the client comfortably.
Assess the client's breathing pattern.
60. A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? Sit quietly with the client until the episode is over. Ignore the behavior. Attempt to divert the client's attention. Tell the client that this behavior is unacceptable.
Attempt to divert the client's attention.
85. Which information should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. Carefully test the temperature of bath water. Avoid kitchen activities because of the risk of injury. Avoid hot water bottles and heating pads. Inspect the skin daily for injury or pressure points. Wear warm clothing when outside in cold temperatures.
Carefully test the temperature of bath water. Avoid hot water bottles and heating pads. Inspect the skin daily for injury or pressure points. Wear warm clothing when outside in cold temperatures.
95. The nurse is caring for an unconscious intubated client with normal intracranial pressure. What should the nurse include in the care plan? Monitor the oral temperature, keep the room temperature at 70°F (21.1°C), and place the client on a cooling blanket if the client's temperature is higher than 101°F (38.3°C). Clean the mouth carefully, apply a thin coat of a water-based lubricant, and move the endotracheal tube to the opposite side daily. Position the client in the supine position with the head to the side and slightly elevated on two pillows. Turn the client with a draw-sheet, and place a pillow behind the back and one between the legs.
Clean the mouth carefully, apply a thin coat of a water-based lubricant, and move the endotracheal tube to the opposite side daily.
9. What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? Compress the nares. Tilt the head back Collect the drainage. Administer an antihistamine for postnasal drip.
Collect the drainage.
64. A health care provider (HCP) has prescribed carbidopa-levodopa four times per day for a client with Parkinson's disease. The client wants "to end it all now that the Parkinson's disease has progressed." What should the nurse do? Select all that apply. Explain that the new prescription for carbidopa-levodopa will treat the depression. Encourage the client to discuss feelings as the carbidopa-levodopa is being administered. Contact the HCP before administering the carbidopa-levodopa. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. Determine if the client is at risk for suicide.
Contact the HCP before administering the carbidopa-levodopa. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. Determine if the client is at risk for suicide.
109. A client is using patient-controlled analgesia (PCA) to manage postoperative pain. What should the nurse do when assisting the client with the PCA? Reassure the client that pain will be relieved. Document the client's response to pain medication. Instruct the client to continue pressing the system's button whenever pain occurs. Titrate pain medication until the client is free from pain.
Document the client's response to pain medication.
76. The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply. Restrict fluids to 1,000 mL/24 hours. Drink 400 to 500 mL with each meal. Drink fluids midmorning, midafternoon, and late afternoon. Attempt to void at least every 2 hours. Use intermittent catheterization as needed.
Drink 400 to 500 mL with each meal. Drink fluids midmorning, midafternoon, and late afternoon. Attempt to void at least every 2 hours. Use intermittent catheterization as needed.
58. The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will do which when eating? Have a preference for foods high in salt. Eat food on only half of the plate. Forget the names of foods. Be unable to swallow liquids.
Eat food on only half of the plate.
1. The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. Encourage the client to cough to expectorate secretions. Elevate the head of the bed 15 to 20 degrees. Contact the health care provider (HCP) if ICP is >28 mm Hg. Monitor neurologic status using the GlasgowComa Scale. Stimulate the client with active range-of-motion exercises.
Elevate the head of the bed 15 to 20 degrees. Contact the health care provider (HCP) if ICP is >28 mm Hg. Monitor neurologic status using the GlasgowComa Scale.
11. A client has an increased intracranial pressure (ICP) of 20 mm Hg. What should the nurse do next? Give the client a warming blanket. Administer low-dose barbiturates. Encourage the client to take deep breaths to hyperventilate. Restrict fluids.
Encourage the client to take deep breaths to hyperventilate
105. A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the client's first response to pain will be to do what? Tolerate the pain. Decrease the perception of pain. Escape the source of pain. Divert attention from the source of pain.
Escape the source of pain.
86. Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? Limit fluid intake to 1,000 mL/day. Insert an indwelling urinary catheter. Establish a regular voiding schedule. Administer prophylactic antibiotics as prescribed.
Establish a regular voiding schedule.
6. An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first? Establish an airway. Determine the identity of the client. Stop bleeding from open wounds. Check for a neck fracture.
Establish an airway.
118. The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do? Have the UAP keep a steady pull on the client to promote forward ambulation. Explain how to overcome a freezing gait by telling the client to march in place. Assist the UAP with getting the client back in bed. Give the client a muscle relaxant.
Explain how to overcome a freezing gait by telling the client to march in place.
54. Which is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? Place the client's feet against a firm footboard. Reposition the client every 2 hours. Have the client wear ankle-high tennis shoes at intervals throughout the day. Massage the client's feet and ankles regularly.
Have the client wear ankle-high tennis shoes at intervals throughout the day.
47. A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activa-for (t-PA)? Ask what medications the client is taking. Complete a history and health assessment. Identify the time of onset of the stroke. Determine if the client is scheduled for any surgical procedures.
Identify the time of onset of the stroke.
104. The nurse finds it difficult to relieve a client's pain satisfactorily. Which measure should the nurse take next when continuing efforts to promote comfort? Increase the client's confidence in the nurse. Enlist the help of the client's family. Allow the client additional time to work through his or her own responses to pain. Arrange to have the client share a room with a client who has little pain.
Increase the client's confidence in the nurse.
121. The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first? Ask the family to stay with the client. Contact the health care provider, and request a prescription for soft wrist restraints. Increase the frequency of client observation. Administer a sedative.
Increase the frequency of client observation.
110. A client has a patient-controlled analgesia (PCA) infusion to manage postoperative pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0 to 10 pain scale. What should the nurse do first? Check the patient-controlled analgesia (PCA)pump function. Inspect the infusion site. Assess vital signs. Notify the health care provider (HCP).
Inspect the infusion site.
98. When the nurse performs oral hygiene for an unconscious client, which nursing intervention is the priority? Keep a suction machine available. Place the client in a prone position. Wear sterile gloves while brushing the clients teeth. Use gauze wrapped around the fingers to clean the client's gums.
Keep a suction machine available.
99. The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate? Have the client wear eyeglasses at all times. Lightly tape the eyelid shut. Instill artificial tears once every shift. Clean the eyelid with a washcloth every shift.
Lightly tape the eyelid shut.
94. Which nursing action is a priority during the first 24 hours of hospitalization for a comatose client with suspected drug overdose? Educate regarding drug abuse. Minimize pain. Maintain intact skin. Increase caloric intake.
Maintain intact skin.
31. Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin? Take all the medication until it is gone. Notify the health care provider (HCP) if vision changes occur. Store gabapentin in the refrigerator. Take gabapentin with an antacid to protect against ulcers.
Notify the health care provider (HCP) if vision changes occur.
22. A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do? Count the rate to be sure that ventilations are deep enough to be sufficient. Notify the health care provider (HCP) of the client's breathing pattern. Increase the rate of ventilations. Increase the tidal volume on the ventilator.
Notify the health care provider (HCP) of the client's breathing pattern.
101. When administering intermittent enteral feeding to an unconscious client, what should the nurse do? Heat the formula in a microwave. Place the client in a semi-Fowler's position. Obtain a sterile gavage bag and tubing. Weigh the client before administering the feeding.
Place the client in a semi-Fowler's position.
73. A client with Parkinson's disease needs a long time to complete morning care but becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation? Tell the client firmly that he or she needs assistance and help with the morning care. Praise the client for the desire to be independent and give extra time and encouragement. Tell the client that he or she is being unrealistic about the abilities and must accept the fact that he or she needs help. Suggest to the client to at least modify the morning care routine if he or she insists on self-care.
Praise the client for the desire to be independent and give extra time and encouragement.
61. When communicating with a client who has aphasia, which approaches are helpful? Select all that apply. Present one thought at a time. Avoid writing messages. Speak with normal volume. Make use of gestures. Encourage pointing to the needed object.
Present one thought at a time. Speak with normal volume. Make use of gestures. Encourage pointing to the needed object.
102. The unconscious client is to receive 200 ml of tube feeding every 4 hours. The nurse checks for he client's gastric residual before administering the next scheduled feeding and obtains 40 mL, of gastric residual. What should the nurse do next? Withhold the tube feeding, and notify the health care provider (HCP). Dispose of the residual, and continue with the feeding. Delay feeding the client for 1 hour, and then recheck the residual. Readminister the residual to the client, and continue with the feeding.
Readminister the residual to the client, and continue with the feeding.
114. When caring for a client with Guillain-Barré syndrome, the nurse can delegate which activity to the the unlicensed assistive personnel (UAP)? Assess weakness with range-of-motion exercises. Reposition client every 2 hours. Suction the endotracheal tube. Show the client how to do deep-breathing exercises.
Reposition client every 2 hours.
36. The health care provider has prescribed phenytoin sodium therapy for a client with seizures. What should the nurse explain to the client about stopping the drug suddenly? Physical dependency develops over time. Status epilepticus may occur. A hypoglycemic reaction is likely. Heart block can happen.
Status epilepticus may occur.
63. Which nursing approach is most helpful to a client with Parkinson's disease who is experiencing a freezing of gait with difficulty initiating movement? Pull the client forward to initiate walking. Instruct the client to use a wheelchair. Have the client remain still. Tell the client to march in place.
Tell the client to march in place.
96. The unconscious client is to be placed in a right side-lying position. The nurse should intervene when observing a client in which position? The head is placed on a small pillow. The right leg is extended without pillow support. The left arm is rested on the mattress with the elbow flexed. The left leg is supported on a pillow with the knee flexed.
The left arm is rested on the mattress with the elbow flexed.
116. The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which intervention should the nurse consider? Have the client hyperextend the neck when swallowing. Tell the client to place the chin firmly against the chest when eating. Thicken all liquids before offering to the client. Place the client on a clear liquid diet.
Thicken all liquids before offering to the client.
59. A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? Wear a patch over one eye. Place personal items on the sighted side. Lie in bed with the unaffected side toward the door. Turn the head from side to side when walking.
Turn the head from side to side when walking.
16. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. What should the nurse do to protect the client without increasing the intracranial pressure (ICP)? Place the client in a jacket restraint. Wrap the hands in soft "mitten" restraints. Tuck the arms and hands under the sheet. Apply a wrist restraint to each arm.
Wrap the hands in soft "mitten" restraints.
117. After receiving a change-of-shift report at 0700, the nurse should assess which client first? a 23-year-old with a migraine headache who has severe nausea associated with retching a 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching a 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast a 63-year-old with multiple sclerosis who has an oral temperature of 101.80F (38.8°C) and flank pain
a 63-year-old with multiple sclerosis who has an oral temperature of 101.80F (38.8°C) and flank pain
65. Which is an initial sign of Parkinson's disease? rigidity tremor bradykinesia akinesia
tremor
29. The client will have an electroencephalogram (EEG) in the morning. The nurse should do instruct the client to have which foods/fluids for breakfast? no food or fluids only coffee or tea if needed a full breakfast as desired without coffee, tea, or energy drinks a liquid breakfast of fruit juice, oatmeal, or smoothie
a full breakfast as desired without coffee, tea, or energy drinks
37. The nurse is teaching a client with seizures to recognize an aura. What should the nurse instruct the client to notice as an onset of an aura? a postictal state of amnesia a hallucination that occurs during a seizure a symptom that occurs just before a seizure a feeling of relaxation as the seizure begins to subside
a symptom that occurs just before a seizure
106. Ergotamine tartrate is prescribed for a client's migraine headaches. What is an expected outcome of the use of this drug? prevention of the migraine aborting of the developing migraine relief from the sleeplessness experienced in the past after a migraine relief from the vision problems experienced in the past after a migraine
aborting of the developing migraine
91. A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in the car, and a drug overdose is suspected. Which medication should the nurse have available for further emergency treatment? vitamin K dextrose 50% activated charcoal powder sodium thiosulfate
activated charcoal powder
18. A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client? The client will: exhibit no further episodes of short-term memory loss. be able to return to his construction job in 3 weeks. actively participate in the rehabilitation process as appropriate. be emotionally stable and display preinjury personality traits.
actively participate in the rehabilitation process as appropriate.
80. When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? encouraging the client to speak slowly encouraging the client to speak distinctly asking the client to repeat indistinguishable words asking the client to speak louder when tired
asking the client to speak louder when tired
88. When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for which health problem? aspiration bladder dysfunction hypertension sensory loss
aspiration
108. A client is receiving massage therapy to relieve pain. Which statement explains why massage is an effective way to relieve pain? Massage therapy: blocks pain impulses from the spinal cord to the brain. blocks pain impulses from the brain to the spinal cord. stimulates the release of endorphins. distracts the client's focus on the source of the pain.
blocks pain impulses from the spinal cord to the brain.
48. A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign? pulse respirations blood pressure temperature
blood pressure
24. A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temperature 99°F (37°C), pulse 100 bpm, respirations 18 breaths/min, and blood pressure 140/70 mm Hg. The nurse should report which changes should they occur to the health care provider (HCP)? Select all that apply. decreasing urinary output decreasing systolic blood pressure bradycardia widening pulse pressure tachycardia increasing diastolic blood pressure
bradycardia widening pulse pressure
17. Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? deep breathing turning coughing passive range-of-motion (ROM) exercises
coughing
12. The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition? widening pulse pressure decrease in the pulse rate dilated, fixed pupils decrease in level of consciousness (LOC)
decrease in level of consciousness (LOC)
111. A client is using healing touch therapy to manage pain. What should the nurse tell the client about how healing touch can be effective in pain management? Healing touch involves: directing the flow of energy fields. lightly touching the client skin. massaging the client's muscles. increasing endorphin production.
directing the flow of energy fields.
62. What is the expected outcome of thrombolytic drug therapy for stroke? increased vascular permeability vasoconstriction dissolved emboli prevention of hemorrhage
dissolved emboli
35. The nurse is assessing a client in the post-ictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has which symptom following the seizure? drowsiness inability to move paresthesia hypotension
drowsiness
23. The nurse is planning the care for a client who has had a posterior fossa (infratentorial) cranitomy. What should the nurse avoid when positioning the client? keeping the client flat on one side or the other elevating the head of the bed to 30 degrees logrolling or turning as a unit when turning keeping the neck in a neutral position
elevating the head of the bed to 30 degrees
39. Which clinical manifestation is a typical reaction to long-term phenytoin sodium therapy? weight gain insomnia excessive growth of gum tissue deteriorating eyesight
excessive growth of gum tissue
79. A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? The client: exhibits intolerance to many drugs. experiences spontaneous remissions from time to time. requires multiple drugs simultaneously. endures long periods of exacerbation before the illness responds to a particular drug.
experiences spontaneous remissions from time to time.
20. The nurse is assessing a client's motor response after brain surgery, The nurse pinches the clients skin to elicit a response and observes the clients arms and legs moving straight out and the feet and toes bend downward. How should the nurse document this response? flaccid paralysis flexion posturing chronic spastic paralysis extension posturing
extension posturing
75. When assessing the client with multiple sclerosis for potential complications of the disease, the nurse should asses the client for which symptoms? Select all that apply. dehydration falls seizures skin breakdown fatigue
falls skin breakdown fatigue
15. The nurse is assessing a client for movement after halo traction placement for a C8 fracture. What should the nurse do to test the client's ability to move? Ask the client to: shrug shoulders against downward resistance. pull arm up from a resting position against resistance. straighten arm from a flexed position against resistance. grasp the nurse's hands with both hands and squeeze.
grasp the nurse's hands with both hands and squeeze.
51. The nurse is developing a care plan for a client who has had a stroke. The nurse asks about the client's functional status before the stroke. How will the nurse incorporate this information into the care plan? The client's functional status before the stroke will: guide the rehabilitation plan. help predict outcomes. help the client recognize physical limitations. determine if the client can be expected to regain most functional status.
guide the rehabilitation plan.
41. Which outcomes indicate effective management of a conscious client who is being treated with recombinant tissue plasminogen therapy during the initial phase of an ischemic cerebral vascular accident (CVA)? Select all that apply. headache reduced dysphagia improved visual disturbances improved responds to comfort measures no signs or symptoms of bleeding
headache reduced responds to comfort measures no signs or symptoms of bleeding
74. Which is an expected outcome for a client with Parkinson's disease who has had a pallidotomy? improved functional ability reduced emotional stress increased alertness better appetite
improved functional ability
83. Which nursing goal is realistic to establish with a client who has multiple sclerosis (MS)? greater joint flexibility improved muscle strength clearer thinking fewer mood swings
improved muscle strength
14. The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring? muscle relaxation intake and output widening of the pulse pressure pupil dilation
intake and output
42. A client admitted with possible ischemic stroke has been aphasic for 3 hours and has a blood pressure (BP) of 220/120 mm Hg. Which prescription by the health care provider should the nurse question? labetalol drip to keep the blood pressure<120/80 mm Hg tissue plasminogen activator (tPA) per protocol normal saline intravenously at 75 mL/h bed elevated 30 degrees
labetalol drip to keep the blood pressure<120/80 mm Hg
82. A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? eating a diet high in fiber setting a regular time for elimination using an elevated toilet seat limiting fluid intake to 1,000 mL/ day
limiting fluid intake to 1,000 mL/ day
27. Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? jerking in one extremity that spreads gradually to adjacent areas vacant staring and abruptly ceasing all activity facial grimaces, patting motions, and lip smacking loss of consciousness, body stiffening, and violent muscle contractions
loss of consciousness, body stiffening, and violent muscle contractions
66. The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which topic is most important to include in the plan? maintaining a balanced nutritional diet enhancing the immune system maintaining a safe environment engaging in diversional activity
maintaining a safe environment
97. What finding indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful? preservation of muscle mass prevention of bone demineralization increase in muscle tone maintenance of joint mobility
maintenance of joint mobility
34. What nursing assessments should be documented at the beginning of the ictal phase of a seizure? heart rate, respirations, pulse oximeter, and blood pressure last dose of anticonvulsant and circumstances at the time type of visual, auditory, and olfactory aura the client experienced movement of the head and eyes and muscle rigidity
movement of the head and eyes and muscle rigidity
71. A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy? mood muscle rigidity appetite alertness
muscle rigidity
55. The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. which position is appropriate? Select all that apply. placing a pillow in the axilla so the arm is away from the body inserting a pillow under the slightly flexed arm so the hand is higher than the elbow immobilizing the extremity in a sling positioning a hand cone in the hand so the fingers are barely flexed keeping the arm at the side using a pillow
placing a pillow in the axilla so the arm is away from the body inserting a pillow under the slightly flexed arm so the hand is higher than the elbow positioning a hand cone in the hand so the fingers are barely flexed
46. The nurse is observing the unlicensed assistive personnel (UAP) give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which? positions the client on the back with a small pillow under the head keeps portable suctioning equipment at the bedside opens the client's mouth with a padded tongue blade cleans the client's mouth and teeth with a toothbrush
positions the client on the back with a small pillow under the head
115. An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction? providing passive range- of-motion exercises to the left extremities during the bed bath elevating the foot of the bed to reduce edema pulling up the client under the left shoulder when getting the client out of bed to a chair putting high top tennis shoes on the client after bathing
pulling up the client under the left shoulder when getting the client out of bed to a chair
49. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? cholesterol level of pupil size and pupillary response bowel sounds echocardiogram
pupil size and pupillary response
87. A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial? psychotherapy regular exercise day care for the granddaughter weekly visits by another person with MS
regular exercise
78. A client with multiple sclerosis (MS) is receiving baclofen. The nurse determines that the drug is effective when it produces which outcome? induces sleep stimulates the client's appetite relieves muscular spasticity reduces the urine bacterial count
relieves muscular spasticity
100. Which sign is an early indicator of hypoxia in the unconscious client? cyanosis decreased respirations restlessness hypotension
restlessness
52. Which positioning technique is most effective when there is only one person to assist the client to move from the left side to the right side if the client has hemiparalysis? rolling the client onto the side sliding the client to move up in bed lifting the client when moving the client up in bed 4. having the client help lift off the bed using a trapeze
rolling the client onto the side
40. A 21-year-old female client takes clonazepam. What should the nurse ask this client about? Select all that apply. seizure activity pregnancy status alcohol use cigarette smoking intake of caffeine and sugary drinks
seizure activity pregnancy status alcohol use
10. Which respiratory pattern indicates increasing intracranial pressure in the brain stem? slow, irregular respirations rapid, shallow respirations asymmetric chest excursion nasal flaring
slow, irregular respirations
77. Which is not a typical clinical manifestation of multiple sclerosis (MS)? double vision sudden bursts of energy weakness in the extremities muscle tremors
sudden bursts of energy
2. The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. systolic blood pressure urine output breath sounds cerebral perfusion pressure level of pain
systolic blood pressure cerebral perfusion pressure
13. The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? the head of the bed elevated 15 to 20 degrees Trendelenburg's position left Sims' position the head elevated on two pillows
the head of the bed elevated 15 to 20 degrees
70. Which goal is collaboratively established by the client with Parkinson's disease, the nurse, and the physical therapist? to maintain joint flexibility to build muscle strength to improve muscle endurance to reduce ataxia
to maintain joint flexibility
69. Which goal is the most realistic for a client diagnosed with Parkinson's disease? to cure the disease to stop progression of the disease to begin preparations for terminal care to maintain optimal body function
to maintain optimal body function
107. A client is using biofeedback to manage pain. The nurse can explain to the client that biofeedback will enable the client to exert control over physiologic processes by which mechanism? regulating the body processes through electrical control shocking the client when an undesirable response is elicited monitoring the body processes for the therapist to interpret translating the signals of body processes into observable forms
translating the signals of body processes into observable forms
8. A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? unequal pupil size decreasing systolic blood pressure tachvcardia decreasing body temperature
unequal pupil size
92. Which clinical manifestations should the nurse expect to assess in a client diagnosed with an overdose of a cholinergic agent? Select all that apply. dry mucous membranes urinary incontinence central nervous system (CNS) depression seizures skin rash
urinary incontinence central nervous system (CNS) depression seizures
56. For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? speaking loudly and slowly using a "picture board" for the client to point to pictures writing directions so the client can read them speaking in short sentences
using a "picture board" for the client to point to pictures
72. A client is being switched from levodopa (L-dopa) to carbidopa-levodopa. The nurse should monitor for which possible complication during medication changes and dosage adjustment? euphoria jaundice vital sign fluctuation signs and symptoms of diabetes
vital sign fluctuation
