Med Surg II Exam 3

Which statement by a nurse regarding a first-degree strain indicates a need for further learning? "The symptoms of a first-degree strain can last for several days." "A first-degree strain demonstrates minimal inflammation and pain." "A first-degree strain is also known as a moderate strain." "Range of motion remains unaffected in a first-degree strain."

"A first-degree strain is also known as a moderate strain."

How would the nurse explain to the patient the difference between a strain and a sprain?

"A sprain is the stretching or tearing of a ligament; a strain is the stretching or tearing of a muscle or tendon."

The nurse is discussing treatment with a patient who has a brain tumor and is receiving chemotherapy. Which statement made by the patient indicates a need for further teaching? "I should wear a hat while going out." "I should stop taking glucocorticoids when I feel normal." "I should rinse my mouth with alcohol-free mouthwash." "I should consult the primary healthcare provider when a dose of antiepileptic medication is missed."

"I should stop taking glucocorticoids when I feel normal." need to be tapered

The nurse is teaching a patient about seizure management. Which statement by the patient about this image demonstrates understanding? *seizure bracelet* "I should wear this all of the time." "If I don't have it on, I can tell people I have a seizure disorder." "I only need to wear this when I leave the house." "This will help me if I get pulled over when driving."

"I should wear this all of the time."

The nurse is providing client teaching regarding the use of phenytoin and is aware the client requires further teaching when the client makes which statement? "I know that I must follow my medication regimen." "If I feel ill, it is okay for me to stop taking this medication." "I should refill my prescription before it runs out." "I should have regular dental checkups."

"If I feel ill, it is okay for me to stop taking this medication."

A nurse is teaching about second-degree sprains. Which statement indicates a need for further teaching? "It can also be considered as a moderate sprain." "It prevents a patient from ambulating due to joint instability." "It leads to increased swelling, ecchymosis, pain, and altered weight-bearing mobility." "It results from a significantly moderate amount of tearing in the ligament fibers."

"It prevents a patient from ambulating due to joint instability."

A patient recently obtained a fracture and is asking the nurse about nonsurgical management of bone fractures. Which statements by the nurse are correct? Select all that apply. "Nonsurgical management of bone fractures can be achieved with the help of splints." "External fixation is a form of nonsurgical management of bone fractures." "Nonsurgical management of bone fractures can be achieved with the help of casts." "Open reduction with internal fixation is a form of nonsurgical management of bone fractures." "Closed reduction is a form of nonsurgical management of bone fractures."

"Nonsurgical management of bone fractures can be achieved with the help of splints." "Nonsurgical management of bone fractures can be achieved with the help of casts." "Closed reduction is a form of nonsurgical management of bone fractures."

The nurse is teaching about myasthenia gravis (MG) with a newly diagnosed patient. Which statement by the patient indicates a need for further teaching? "The symptoms include localized skeletal muscle weakness, ptosis, diplopia, and fatigue." "Penicillamine is used in the treatment of MG." "Serological tests and electromyography are used in the diagnosis of MG." "Plasmapheresis is an additional therapy used in the treatment of MG."

"Penicillamine is used in the treatment of MG."

The nurse is caring for a client who is considering the implantation of a vagal nerve stimulator (VNS) to treat and control seizures. The nurse knows the client understands the purpose of the VNS when she makes which statement? "Electrodes are placed in deep brain structures and programmed to activate when the seizure activity is sensed." "I will be admitted to the hospital for at least a week to have the VNS implanted." "The VNS will either fire continuously or I may have to carry a magnet to activate the stimulator when I feel the presence of an aura." "The connection between the right and left hemisphere of the brain will be severed."

"The VNS will either fire continuously or I may have to carry a magnet to activate the stimulator when I feel the presence of an aura."

The charge nurse asks the student nurse to gather supplies to set up suction for a seizure client who is going to be admitted to the nursing unit. The student nurse asks why this equipment is needed. How should the charge nurse respond? "The client may not be able to protect the airway after the seizure and suctioning may be required." "The healthcare provider ordered it, so we are required to do it." "It will be available if the client wishes to use the equipment." "The client may have aspirated before coming to the hospital and the nursing staff may need to suction out the aspirate."

"The client may not be able to protect the airway after the seizure and suctioning may be required."

The nurse is preparing to give the client who had a craniotomy an oral stool softener. The client's wife asks why the client needs this medication and says the client rarely has problems with constipation. What is the nurse's best response? "The doctor ordered the medicine, so the client needs to receive it." "The client needs to avoid straining to have a bowel movement." "If the client does not want to take the stool softener, it is fine with me." "At times a client gets constipated, and the doctor wants to prevent that."

"The client needs to avoid straining to have a bowel movement."

The nurse is caring for a patient who is prescribed carbamazepine for complex partial seizures. Which is the most appropriate information for the nurse to teach the patient? "The medication must be chewed." "The medication may cause blurred vision." "Weight gain is a side effect of the medication." "The medication may cause sedation."

"The medication may cause blurred vision."

The nurse is discharging a patient after surgery for a brain tumor who will be performing blood glucose monitoring at home. The patient asks why this is necessary. How should the nurse respond? "The tumor has caused you to become diabetic." "The medications to decrease swelling cause blood glucose levels to rise." "Having high blood glucose causes the tumor to grow back." "This is a healthy lifestyle choice."

"The medications to decrease swelling cause blood glucose levels to rise."

The client with a brain tumor is being discharged from the hospital. The nurse is explaining that the blood glucose must be monitored for a period of time after discharge. The client states, "Do I now have diabetes to deal with also?" What would be the nurse's best response? "It is difficult to tell at this time; your glucose has been high during your hospital stay. We will have to wait and see." "The steroids you have been taking can cause hyperglycemia. When the steroids are finished, blood sugar typically will return to normal." "I cannot answer your question. You must talk to your healthcare provider about your concerns." "Yes, you are diabetic and will have to check your blood sugar four times a day for the rest of your life."

"The steroids you have been taking can cause hyperglycemia. When the steroids are finished, blood sugar typically will return to normal."

The adult who has had his first complex partial seizure is asking the nurse when he can drive again. What is the best response to the client regarding this question? "The doctor usually lets clients drive upon discharge." "You will need to notify the Department of Motor Vehicles about your condition. Each state has different rules and regulations." "You will need to notify the national Department of Motor Vehicles about your condition. The rules are the same for every state." "I doubt you will ever drive again, but there are public transportation options that you can explore."

"You will need to notify the Department of Motor Vehicles about your condition. Each state has different rules and regulations."

The nurse is caring for the postoperative client after a craniotomy and would like to decrease intracranial pressure. At which angle should the nurse place the head of the bed? 15-30 degrees 30-45 degrees 45-60 degrees 60-75 degrees

30-45 degrees

The nurse caring for a client who is post status epilepticus is aware that status epilepticus can be caused by which conditions? Select all that apply. Anaphylactic reaction to medication Abrupt withdrawal of anticonvulsive medications Myocardial infarction Acute drug withdrawal Head trauma

Abrupt withdrawal of anticonvulsive medications Acute drug withdrawal Head trauma

Which nursing actions should a nurse take for a patient who has undergone amputation? Select all that apply. Place a pillow under the remaining portion of the lower extremity. Administer analgesics as per the order. Apply ice for at least an hour on the site. Apply a rigid cast or splint. Encourage intake of additional protein- and carbohydrate-rich foods.

Administer analgesics as per the order. Apply a rigid cast or splint. Encourage intake of additional protein- and carbohydrate-rich foods.

Which intervention should the nurse implement for the patient with increased intracranial pressure following a brain tumor resection? Administer stool softeners. Position the patient in a supine position at all times. Apply sequential compression devices. Encourage the patient to use a non-alcohol containing mouth wash.

Administer stool softeners.

The registered nurse (RN) is providing postsurgical care for a patient with a brain tumor. Which nursing action helps to prevent cerebral edema? Administering glucocorticoids to the patient Positioning the patient's head at a 15° angle Applying a sequential compression device to the patient Administrating benzodiazepines to the patient

Administering glucocorticoids to the patient

Which precautionary measure should a nurse take when administering pyridostigmine to a patient when treating myasthenia gravis (MG)? Monitoring the blood glucose level, which may fluctuate Administering the medication 30 to 60 minutes before a meal Checking if calcium and vitamin D supplements have been ordered Educating the patient about side effects of steroids

Administering the medication 30 to 60 minutes before a meal

Which should a nurse keep in mind when caring for a patient with a traumatic amputation? Select all that apply. Apply a tourniquet to the remaining limb. Salvage surgery may be ordered for the patient by the primary healthcare provider. A coagulation panel, complete blood count (CBC), and serum lactate baseline level should be established. The Phalen test may be performed on the patient . The Steinman test may be performed on the patient .

Apply a tourniquet to the remaining limb. Salvage surgery may be ordered for the patient by the primary healthcare provider. A coagulation panel, complete blood count (CBC), and serum lactate baseline level should be established. Phalen test = carpal tunnel Steinman test = meniscus injury

Which nursing action helps in preventing venous thromboembolism in a patient who is postcraniotomy? Administering stool softeners to the patient Instructing the patient to use a soft toothbrush Elevating the patient's head of the bed to a 45-degree angle Applying a sequential compression device to the patient

Applying a sequential compression device to the patient

A nurse is taking care of an athlete who has a first-degree sprain in the ankle. Which action by the nurse indicates a need for further training? Advising the patient to rest the injured extremity up to 72 hours Applying ice for at least 60 minutes at a stretch only for the first 24 hours after injury Applying a compression dressing Elevating the affected area

Applying ice for at least 60 minutes at a stretch only for the first 24 hours after injury

What is the focus of interdisciplinary care for clients as Alzheimer's disease progresses? Stopping progression of the disease by use of pharmacological agents Assisting client and family members with supportive care Initiating the use of nutritional therapies Preventing development of deep vein thrombosis

Assisting client and family members with supportive care

A patient who has undergone a Tensilon test for the detection of myasthenia gravis (MG) has developed bradycardia. Which drug will be most beneficial for the patient? Atropine Neostigmine Pyridostigmine Mycophenolate mofetil

Atropine rest are treatment for MG

The nurse asked a family member of a client with seizures if the client exhibited automatisms with the most recent seizure. The family member asked for clarification on what the term automatisms meant. How should the nurse respond? Automatisms are odors, visualizations, and/or hallucinations that occur just prior to the beginning of the seizure. Automatisms are symptoms such as drowsiness, confusion, and disorientation that occur immediately after the seizure. Automatisms are repetitive unconscious movements such as chewing or lip smacking. Automatisms are the tonic/clonic movement seen in some types of seizures.

Automatisms are repetitive unconscious movements such as chewing or lip smacking.

Which method allows for a definitive diagnosis of Alzheimer's disease? Computed tomography scan of the brain Microscopic observation of neurofibrillary tangles Autopsy Review of client history and symptomology

Autopsy

What common complications should the nurse assess for in a client with a brain tumor? Select all that apply. Bleeding Seizures Venous thrombus embolism Decline in kidney function Cerebral edema

Bleeding Seizures Venous thrombus embolism Cerebral edema

The nurse is caring for a client who has had surgery to remove a brain tumor. The nurse would carefully assess the client for which potential complication? Select all that apply. Bleeding Decreased intracranial pressure Venous thromboembolism Congestive heart failure Seizures

Bleeding Venous thromboembolism Seizures

The nurse monitors the heart rate of a client with Alzheimer's disease before giving treatment medication because of which potential complication? Premature atrial contractions Atrial fibrillation Bradycardia Atrial flutter

Bradycardia

When caring for a patient with increased intracranial pressure (ICP), the nurse should be monitoring for which high-risk complication? Hypertensive crisis Brainstem herniation Cardiac dysrhythmias Stroke

Brainstem herniation

A patient reports a sharp, throbbing, and shocklike pain after brushing the teeth, smiling, or talking. Which medication is the most appropriate as first-line therapy? Baclofen Gabapentin Carbamazepine Oxcarbazepine

Carbamazepine

The nurse is aware that the client with a brain tumor can be medically managed with which treatments? Select all that apply. Chemotherapy Radiation Surgery Bone marrow transplant Blood transfusion

Chemotherapy Radiation Surgery

Which type of fracture creates an external wound that exposes the fracture site? Complete Simple Compound Incomplete

Compound

Which client issues are priorities of nursing care for a client diagnosed with Alzheimer's disease? Select all that apply. Confusion Problems with coping Fluid and electrolyte imbalance Caregiver strain Mobility issues

Confusion Problems with coping Fluid and electrolyte imbalance Caregiver strain (safety & hydration are key)

Which assessment findings would provide an indication of increased intracranial pressure? Select all that apply. Oxygen saturation Decreased alertness Increased blood pressure Personality changes Swelling of the optic disc

Decreased alertness Personality changes Swelling of the optic disc

Which clinical manifestation should a nurse look for in a patient with myasthenia gravis (MG)? Facial pain Areflexia Diplopia Paralysis

Diplopia

The nurse is viewing an x-ray of a patient who has experienced a fracture. The image shows malalignment of bone fragments at the fracture site. What type of fracture should the nurse document? Oblique Spiral Displaced Depressed

Displaced

While caring of a patient who underwent surgical repair of a fracture, the nurse finds edema in the area where the surgery occurred. Which should the nurse assess next based on these findings? Elevated temperature Level of independence Distal pulses Loss of sensation

Distal pulses *edema signs poor perfusion*

In which state of a seizure is a patient most likely to have compromised airway and decreased level of consciousness? After a seizure episode During the preictal state During the postictal state Between seizure episodes

During the postictal state

Which are symptoms of the acute phase of Guillain-Barre syndrome (GBS)? Select all that apply. Edema Inflammation Remyelination Axonal regeneration Peripheral nerve demyelination

Edema Inflammation Peripheral nerve demyelination other 2 are recovery

Which interventions should the nurse implement for the patient with Parkinson's disease (PD)? Select all that apply. Elevate head of bed when eating and drinking. Arrange speech therapy for the patient. Teach the patient to take long steps while walking. Teach the patient to call the healthcare provider for medical compliance. Discuss and evaluate the patient's ability to drive.

Elevate head of bed when eating and drinking. Arrange speech therapy for the patient. Teach the patient to call the healthcare provider for medical compliance. Discuss and evaluate the patient's ability to drive.

Which confirms the diagnosis of Alzheimer's disease (AD)? Neuropsychiatric testing Written and oral testing Examination of the brain following death Examination of cerebrospinal fluid

Examination of the brain following death

Which is an example of low-energy trauma with reference to fractures? Falls Motor vehicle collisions Injury from contact sports Bicycle accident

Falls

The nurse is caring for a patient post-open reduction internal fixation surgery. The nurse is aware that which complications could develop in this patient? Select all that apply.

Fat embolism syndrome Hypovolemia Respiratory distress

The nurse expects to find the client receiving chemotherapy for a brain tumor exhibiting which signs and symptoms? Select all that apply. Fatigue Weight gain Mucositis Hair loss Reddening of skin

Fatigue Mucositis Hair loss

After assessing a patient with a fracture, the nurse documents a grade II open fracture. Which manifestations in the patient support the nurse's documentation? Select all that apply. Intact vasculature Fragments of broken bone Significant wound contamination Minimal injury to the soft tissues Severe damage to the blood vessels

Fragments of broken bone Significant wound contamination

The nurse is aware that a serious complication of an open fracture is osteomyelitis. If the osteomyelitis is not treated promptly, which further complications can occur? Select all that apply.

Gas gangrene Tetanus

The computed tomography reports of a patient show a glioma located near the brainstem. Which grade of brain tumor does the patient have? Grade I Grade II Grade III Grade IV

Grade IV

The nurse is teaching a community group about carpal tunnel syndrome (CTS). What should be included in teaching? It is the most frequent compression neuropathy of the legs. This syndrome usually occurs in children. Men are four to five times more likely to get CTS than are women. Higher occurrences are seen in computer operators and construction workers.

Higher occurrences are seen in computer operators and construction workers.

Which is true regarding percutaneous rhizotomy to treat trigeminal neuralgia? Select all that apply. In this process, a needle is inserted through the cheek into the foramen ovale. In this process, a lesion forms, which interrupts pain transmission to the brain. In this process, nerve fibers are damaged or destroyed. In this process, a shredded fluorocarbon resin pad is placed between the vessels and the nerve. In this process, patients may experience permanent facial numbness.

In this process, a needle is inserted through the cheek into the foramen ovale. In this process, nerve fibers are damaged or destroyed. In this process, patients may experience permanent facial numbness.

What is the primary reason clients with Alzheimer's disease are at high risk for safety concerns? Inability to remember long-term events in their life Inability to answer questions and difficulty with finding appropriate words Heightened ability to perform answers to mathematical questions Inability to accurately assess their surroundings

Inability to accurately assess their surroundings

The majority of medications used in the treatment of Alzheimer's disease focus on which pharmacological pathway? Increasing enzyme action of acetylcholinesterase Increasing enzyme action of butylcholinesterase Increasing oxidative stress Increasing levels of acetylcholine

Increasing levels of acetylcholine

Clients with Alzheimer's disease are more at risk for which of the following? Select all that apply. Infection Falls Dysphagia Pneumonia Dehydration

Infection Falls Pneumonia Dehydration

After a conversation with a provider, a patient asks what a psychogenic nonepileptic attack disorder (PNES) is. How should the nurse explain it? It does not involve abnormal electrical discharges. It is provoked by other disorders and conditions. It is a chronic disorder. It is an uncontrolled, sudden, excessive discharge of electrical activity.

It does not involve abnormal electrical discharges.

Which is true regarding a compression fracture? It occurs around the shaft of the bone. It occurs at a 45° angle across the cortex of the bone. It occurs as a result of overstretching and tearing of a tendon or ligament. It occurs as a result of excessive force along the axis of cancellous bone.

It occurs as a result of excessive force along the axis of cancellous bone.

The nurse is caring for an older client who has been diagnosed with osteoporosis. The nurse explains to the client that vertebral compression fractures are common with osteoporosis and can result in which condition? Lordosis Scoliosis Spinosis Kyphosis

Kyphosis

The nurse would expect to place the client who just had a seizure in which position? Right-lying (lateral) Left-lying (lateral) Supine Supine with head elevated 15 degrees

Left-lying (lateral)

Which is a first-line medication used in the immediate treatment of seizures and status epilepticus? Select all that apply. Propofol Phenytoin Lorazepam Midazolam Levetiracetam

Lorazepam Midazolam

The nurse is caring for a client with a metastatic brain tumor. What are the most common locations of the primary cancer? Select all that apply. Liver Lung Melanoma Renal Breast

Lung Melanoma Renal Breast

The nurse is developing a plan of care for a patient with Alzheimer's disease recently admitted to a nursing home. What priority goals should the nurse consider? Select all that apply. Maintain patient safety Socialization with residents Improve the quality of life Perform ADLs independently Independently take medications

Maintain patient safety Improve the quality of life

Anticholinergics are used to reduce tremors and drooling associated with Parkinson's disease (PD). Which side effect of this drug contraindicates it for older patients? Memory impairment Urinary frequency Nausea and vomiting Disorders of impulse control

Memory impairment

The nurse is caring for a patient with a history of lung cancer. After presenting to the clinic with headaches, the provider obtains this image. What type of tumor is most likely the cause? Primary Gliomas Oligodendrogliomas Metastatic

Metastatic

Which statement best describes a strain? Dislocation injury Compression injury Ligament injury Muscle or tendon injury

Muscle or tendon injury

A patient is diagnosed with myasthenia gravis (MG). The patient also has paralytic ileus and is unable to take oral medication. Which medication is most likely to benefit the patient? Neostigmine Azathioprine Cyclosporine Mycophenolate mofetil

Neostigmine rest are oral

The nurse is performing an assessment for a patient with a cast experiencing pain at rest, pressure, and paresthesia of the distal extremity. What could cause these symptoms? Rhabdomyolysis Neurovascular compromise Hypovolemia Hypoxia

Neurovascular compromise

The nurse is caring for the patient with a recent lower extremity injury. During the physical assessment, the nurse would include which components in the inspection and palpation of the injury? Select all that apply.

Pallor Pulselessness Movement Sensation

The nurse is caring for a client with a blunt trauma and tissue injury to the lower extremity. Which signs could develop in a client with compartment syndrome? Increased pain in the affected extremity upon ambulation Numbness in the toes of the affected extremity Passive pain at rest in the affected extremity Absence of pain in the affected extremity

Passive pain at rest in the affected extremity

The nurse is caring for four patients with different types of fractures. Which patient requires deep breathing exercises with the use of incentive spirometry? Patient 1 - ribs, RR=24 Patient 2 - mandibular, risk for aspiration Patient 3 - humerus, receiving IV pain med Patient 4 - phalanges, in cast

Patient 1 - ribs, RR=24

Which patient is most likely to experience atonic seizures? Patient A - 13, lip smacking, confusion, limping that last 1-3 mins Patient B - 4, unconscious, sudden loss of movement, head drop due to fall Patient C - 10, slight hand movements, lip smacking, inattentiveness that last 5-10 seconds Patient D - 27, spatial disorientation, inability to speak

Patient B - 4, unconscious, sudden loss of movement, head drop due to fall A = complex partial C = absence D = simple partial

The nurse is caring for a patient with tonic-clonic seizures. Which action of the nurse is most likely to benefit the patient? Encouraging the patient to eat finger foods Placing the patient in a left recumbent position Placing a clock and calendar in the patient's room Encouraging the patient to participate in self-care activities

Placing the patient in a left recumbent position

Which finding is used to diagnose the presence of Parkinson's disease (PD)? Electroencephalogram (EEG) Magnetic resonance imaging (MRI) Cerebrospinal fluid (CSF) testing Presence of tremors and muscular rigidity

Presence of tremors and muscular rigidity CSF = headaches, encephalitis, meningitis EEG = seizures MRI = tumor

Which laboratory finding of cerebrospinal fluid (CSF) indicates the presence of Guillain-Barré syndrome? Pressure: 15 mm Hg Protein: 53 mg/dL Color: cloudy, turbulent Specific gravity: 1.007

Protein: 53 mg/dL

A patient reports difficulty in breathing and chest pain during deep breathing. On assessment, the nurse finds tachycardia, abnormal breath sounds, and bluish coloration of the skin. Which condition can be suspected in the patient? Pulmonary embolism Fat embolism syndrome Compartment syndrome Neurovascular compromise

Pulmonary embolism

The nurse is caring for a patient with this type of traction. What is the purpose? *Skin (Bucks) traction* Relieve muscle spasms Extend the bone in preparation for amputation Bone stabilization Alignment for healing

Relieve muscle spasms

The nurse observes a patient experiencing a partial seizure. Which behavior does the nurse document as automatism? Unilateral, rhythmic muscle movements Rhythmic jerkiness of all extremities Repetitive unconscious movements Visualizations or hallucinations

Repetitive unconscious movements unilateral = partial rhythmic jerking = tonic clonic

The nurse is seeing a patient in the emergency department with a severe sprain to the left ankle. The nurse would include which information in the discharge teaching? Select all that apply.

Rest the injury. Elevate the extremity. Use a compression wrap to the injury.

The nurse is caring for a patient who was involved in a crush injury of the lower extremity and is complaining of severe flank pain and the presence of dark, tea-colored urine. The nurse is aware of the potential for which serious complication?

Rhabdomyolysis

The nurse would expect to carry out which actions while caring for a newly admitted seizure client? Select all that apply. Setting up suction equipment at the client's bedside Having oxygen available at the client's bedside Positioning the client on the right side to prevent aspiration Placing a nasogastric (NG) tube Placing the client on a ventilator

Setting up suction equipment at the client's bedside Having oxygen available at the client's bedside

The home healthcare nurse is caring for an elderly patient with Alzheimer's disease (AD). Which intervention should the nurse implement for the patient? Provide the patient with semi-soft diet. Encourage the patient to take an afternoon nap. Provide the patient with a different schedule every day. Speak calmly using positive statements.

Speak calmly using positive statements.

Which surgical procedure is used to treat the patient with Parkinson's disease (PD)? Vagal nerve stimulator (VNS) Stereotactic pallidotomy Deep brain stimulation Partial corpus callosectomy

Stereotactic pallidotomy VNS & Partial corpus callosectomy = seizures, PCC - tonic clonic or atonic

Which intervention should the nurse implement for a patient who experienced a seizure? Restrain the patient's movements. Assist the patient to a supine position. Suction the oral airway. Encourage the patient to drink water.

Suction the oral airway.

A patient has difficulty ambulating due to joint instability caused by a third-degree sprain. Which treatment is most beneficial for the patient? Surgical repair of the affected area Providing rest to the injured area for four days Providing compression with the help of an Ace wrap Applying ice bags to the affected area for 30 minutes

Surgical repair of the affected area

Which vital signs can be observed in a patient with excessive bleeding that leads to hemorrhagic shock? Select all that apply. Bradypnea Chest pain Tachycardia Low blood pressure Elevated temperature

Tachycardia Low blood pressure

The nurse is caring for a patient undergoing chemotherapy for a brain tumor. Which is the most important nursing intervention for this patient? Encourage use of sunscreen lotion. Provide nutritional supplements. Teach importance of frequent handwashing. Encourage use of skin emollients.

Teach importance of frequent handwashing.

The nurse documents that a patient had an atonic seizure. What did the nurse observe? The patient experienced a brief contracture of muscles or muscle groups. The patient developed shallow breathing and periods of apnea. The patient had rhythmic jerking of all extremities. The patient experienced a severe fall to the ground with loss of consciousness.

The patient experienced a severe fall to the ground with loss of consciousness. rhythmic jerking and shallow breathing = tonic clonic brief contracture = myoclonic

While caring for a patient with a sprain, the nurse refrains from wrapping the dressing very tightly. Which outcome indicates an effective nursing intervention? The patient will have intact sensation. The patient will have decreased bleeding. The patient will have decreased swelling. The patient will not have vasoconstriction.

The patient will have intact sensation.

Which statements would the nurse include in the client and family teaching about the postictal phase of seizures? Select all that apply. The postictal phase occurs after the seizure. The client in the postictal phase may exhibit automatisms such as lip smacking, rhythmic muscle movements, or chewing. The client may exhibit confusion and disorientation during the postictal phase. The postictal phase can last from 5-30 minutes. The postictal phase client may state seeing visualizations, hallucinations, or smell odors that are not present.

The postictal phase occurs after the seizure. The client may exhibit confusion and disorientation during the postictal phase. The postictal phase can last from 5-30 minutes.

Which is true regarding oligodendrogliomas? Select all that apply. They occur during middle age. They are more common in females than in males. They arise from the fatty covering that protects nerves. They arise from the cells that provide support and insulation to axons. They are found in the anterior lobe of the pituitary gland and lead to the hypersecretion of hormones.

They occur during middle age. They arise from the fatty covering that protects nerves. They arise from the cells that provide support and insulation to axons.

The nurse is performing a community assessment and identifying risk factors for traumatic amputations. Which group would most benefit from this education? Those with congenital abnormalities Those with ligament deficiencies Those with industrial jobs requiring the use of power tools Those with osteoarthritis

Those with industrial jobs requiring the use of power tools

The nurse uses cryotherapy in the area of injury for a patient with a sprain. Which is the rationale behind the nurse's intervention? To reduce pain To promote healing To promote mobility To decrease bleeding

To decrease bleeding (apply ice to the area of injury = crypotherapy)

Which describes the role of the speech therapist in terms of care provided for a patient with Parkinson's disease? To maximize independence in activities of daily living (ADLs) To evaluate the patient's ability to swallow To provide exercises that increase strength To promote home safety

To evaluate the patient's ability to swallow

Which is true regarding traction for treating fractures? Select all that apply. Cervical traction is an example of skin traction. Traction can be used in conjunction with surgical/nonsurgical management of fractures. Buck's traction is an example of skeletal traction. Skeletal traction involves the use of pins, tongs, screws, and wires to surgically secure the bone and weight application to provide realignment. Traction involves the use of weights and forces to reduce the fracture and relieve muscle spasms.

Traction can be used in conjunction with surgical/nonsurgical management of fractures. Skeletal traction involves the use of pins, tongs, screws, and wires to surgically secure the bone and weight application to provide realignment. Traction involves the use of weights and forces to reduce the fracture and relieve muscle spasms.

Which assessment finding corresponds with the first stage of Parkinson's disease (PD)? Upper extremity tremors Muscle rigidity Shuffling gait Postural instability

Upper extremity tremors

The nurse would be prepared to monitor which lab values in a client who has undergone pituitary surgery and now has diabetes insipidus as a concern? Select all that apply. Urine specific gravity Serum sodium Urine osmolality Serum chloride Urine ketones

Urine specific gravity Serum sodium Urine osmolality

The nurse is discharging a patient with this appliance. What should the nurse include with the teaching? *Skin (Bucks) traction* Use a plastic hanger to reach under this device if your skin itches. Use a hairdryer on cool settings if it gets wet. Trim or break off any rough edges that are irritating your skin. Rest the heel of your foot on a pillow or bed.

Use a hairdryer on cool settings if it gets wet.

What type of vitamin therapy may be used in the treatment of Alzheimer's disease? Vitamin D Vitamin E Ascorbic acid or vitamin C Vitamin B12

Vitamin E

The nurse is caring for a patient with a femoral shaft facture, and is aware there are three types. Which of these is not a type of femoral shaft fracture?

compound transverse comminuted