MedSurg Quiz

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment would the nurse wear? (Select all that apply.)

Surgical mask Gloves

The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke?

Unilateral weakness during a TIA

The nurse assesses a client who has a history of migraines. Which symptom would the nurse identify as an early sign of a migraine with aura?

Visual disturbances

A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, "I am worried I will not be able to care for my young children." How would the nurse respond?

"Can you tell me more about what worries you, so we can see if we can do something to make adjustments?"

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask?

"Do you live in a crowded residence?"

The nurse assesses a client's recent memory. Which statement by the client confirms that recent memory is intact?

"I ate oatmeal with wheat toast and orange juice for breakfast."

After teaching a client with a high thoracic spinal cord injury, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of how to prevent respiratory problems at home?

"I'll use my incentive spirometer every 2 hours while I'm awake."

After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?

"If I am nauseated, I will not take my epilepsy medication."

A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct?

"Increased pressure from the tumor can cause seizures."

The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver?

"Install safety locks on all outside doors."

The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The daughter asks, "Will the sertraline my mother is taking improve her dementia?" How would the nurse respond about the purpose of the drug?

"It will not improve her dementia but can help control emotional responses."

The nurse teaches assistive personnel (AP) about how to care for a client with early-stage Alzheimer disease. Which statement would the nurse include?

"Reorient the client to the day, time, and environment with each contact."

18. A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How would the nurse document this client's assessment using the Glasgow Coma Scale shown below?

12

The nurse assesses clients on a medical-surgical unit. Which clients would the nurse identify as at risk for secondary seizures? (Select all that apply.)

A 26-year-old woman with a left temporal brain tumor A 38-year-old male client in an alcohol withdrawal program A 42-year-old football player with a traumatic brain injury

A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk for a stroke?

A 27-year-old heavy-cocaine user.

A nurse cares for older clients who have traumatic brain injury. What does the nurse understand about this population? (Select all that apply.)

Admission can overwhelm the coping mechanisms for older clients. These clients are more susceptible to systemic and wound infections. Other medical conditions can complicate treatment for these clients.

A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time?

Assess the client for hypoglycemia and hypoxia.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes, acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first?

Assess the client's serum sodium level.

A nurse plans care for a client with a halo fixator. Which interventions would the nurse include in this client's plan of care? (Select all that apply.)

Assess the pin sites for signs of infection. Assess the chest and back for skin breakdown.

Based on the known risk factors for stroke, which health promotion practices would the nurse teach a client to promote heart health and prevent strokes? (Select all that apply.)

Blood pressure control Aspirin use Smoking cessation Cholesterol management

A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process?

Cardiac dysrhythmias

A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate?

Contact the local organ procurement organization as soon as possible.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor?

Facial flushing

A nurse plans care for a 77-year-old client who is experiencing age-relatedperipheral sensory perception changes. Which intervention would the nurse include in this client's plan of care?

Ensure that the path to the bathroom is free from clutter.

A nurse assesses a client and notes the client's position as indicated in the illustration below:

Decorticate posturing

The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client?

Decreased level of consciousness

A nurse assesses a client with an injury to the medulla. Which clinical manifestations would the nurse expect to find? (Select all that apply.)

Decreased respiratory rate Impaired swallowing Inability to shrug shoulders Loss of gag reflex

A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment finding would be the priority for the nurse to report to the primary health care provider?

Decreasing level of consciousness

A nurse assesses a client who is recovering from an open traditional anterior cervical fusion. Which assessment findings would alert the nursing to a complication from this procedure? (Select all that apply.)

Difficulty swallowing Hoarse voice

3. A client is admitted with a confirmed left middle cerebral artery occlusion. Which assessment findings will the nurse expect? (Select all that apply.)

Dysphagia Aphasia Apraxia Hemiparesis/hemiplegia Ptosis

A nurse is caring for a group of stroke patients. Which clients would the nurse consider referring to a mental health provider? (Select all that apply.)

Female client who exhibits extreme emotional lability Male client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 Female client with mild forgetfulness and a history of depression Male client who has a past hospitalization for a suicide attempt Male client who is unable to walk or eat 3 weeks poststroke

A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury. What other assessment finding will the nurse anticipate for this client?

Flaccid bowel

The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.)

Flexed trunk Slow movements Uncontrolled drooling

The nurse would recognize which signs and symptoms as consistent with brainstem tumors? (Select all that apply.)

Hearing loss Facial pain Nystagmus

The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a stroke for which the nurse would assess for this client? (Select all that apply.)

Heavy alcohol intake Diabetes mellitus Elevated cholesterol Obesity Smoking Hypertension

The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.)

Hyperoxygenate the client before and after suctioning. Avoid sudden or extreme hip or neck flexion. Provide oxygen to maintain an SaO2 of 95% or greater. Avoid clustering care nursing activities and procedures.

The nurse is caring for a client in late-stage Alzheimer disease. Which assessment finding(s) will the nurse anticipate? (Select all that apply.)

Immobile ADL dependent Incontinent Possible seizures

A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion. Which complications would the nurse report to the primary health care provider? (Select all that apply.)

Incisional bulging Clear drainage on the dressing Sudden and severe headache

An 84-year-old client who is usually alert and oriented experiences an acute cognitive decline. Which of the following factors would the nurse anticipate as contributing to this neurologic change? (Select all that apply.)

Infection Drug toxicity Hypoxia

A nurse is discharging a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.)

Is allergic to acetaminophen. Lives alone and is new in town with no friends. Plans to have a beer and go to bed once home.

The nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client's plan of care?

Keep the head of the bed at 30 degrees or greater.

6. When assessing a client who had a traumatic brain injury, the nurse notes that the client is drowsy but easily aroused. What level of consciousness will the nurse document to describe this client's current level of consciousness?

Lethargic

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse anticipate to prepare for administration?

Lorazepam

A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client?

Mannitol

The nurse is preparing for discharge of a client who had a carotid artery angioplasty with stenting to prevent a stroke. For which signs and symptoms with the nurse teach the family to report to the primary health care provider immediately? (Select all that apply.)

Muscle weakness Hoarseness Acute confusion Severe headache Dysphagia

A nurse receives a hand-off report on a female client who had a left-sided stroke with homonymous hemianopsia. What action by the nurse is most appropriate for this client?

Remind the client to move her head from side to side to increase her visual field.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. What actions would the nurse take? (Select all that apply.)

Reposition the client off of the reddened areas. Apply a pressure-reducing mattress.

The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and symptoms consistent with this injury. What signs and symptoms does the nurse expect? (Select all that apply.)

Sensitivity to light and sound Reports "feeling foggy"

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data would the nurse obtain to assess the client's coping strategies? (Select all that apply.)

Spiritual beliefs Family support Level of independence Previous coping strategies

The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct about the administration of this drug?

The drug is not given to clients who are already on anticoagulant or antiplatelet therapy.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain?

Time of symptom onset

12. A nurse performs an assessment of pain discrimination on an older adult. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action would the nurse take next?

Touch the pin on the same area of the left hand.

A client continues to have persistent low back pain even after using a number of nonpharmacologic pain management strategies. Which prescribed drug would the nurse anticipate that the client might need to manage the pain?

Tramadol

A client experiences impaired swallowing after a stroke and has worked with speech- language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met?

Has clear lung sounds on auscultation.

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. Currently the client's neurologic examination is normal. About what drug would the nurse plan to teach the patient?

Clopidogrel

5. A nurse assesses a client recovering from a cerebral angiography via the right femoral artery. Which assessment would the nurse complete?

Palpate bilateral lower extremity pulses.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease?

"He may have trouble chewing, so I will offer bite-sized portions."

4. A nurse asks a client to take deep breaths during an electroencephalography. The client asks, "Why are you asking me to do this?" How would the nurse respond?

"Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity."

11. After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the client's understanding. Which statement indicates client understanding of the teaching?

"I can return to my usual activities immediately after the MRI."

A client diagnosed with Parkinson disease will be starting ropinirole for symptom control. Which statement by the client indicates a need for further teaching?

"I know the drug will probably make help me prevent constipation."

The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." What is the nurse's best response?

"I see you are still hungry. I will get you some toast."

The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate. Which statement by the client indicates a need for further teaching?

"I should report any flulike symptoms to my primary health care provider."

The nurse assesses a client who has meningitis. Which sign(s) and symptom(s) would the nurse anticipate? (Select all that apply.)

Photophobia Decreased level of consciousness Severe headache Fever and chills

A nurse assesses cerebrospinal fluid leaking onto a client's surgical dressing. What actions would the nurse take? (Select all that apply.)

Place the client in a flat position. Report the leak to the surgeon.

8. The nurse is performing an assessment of cranial nerve III. Which testing is appropriate?

Pupil constriction

A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern?

Request a prescription for an antispasmodic drug such as baclofen.

The nurse is taking a history on an older adult. Which factors would the nurse assess as potential risks for low back pain? (Select all that apply.)

Scoliosis Spinal stenosis Hypocalcemia Osteoporosis Osteoarthritis

7. The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V. What assessment findings will the nurse expect for this client?

Severe facial pain

A nurse assesses an older client. Which assessment findings would the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)

Slower processing tiem Change in sleep patterns

A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client's nutritional needs. Which response by the nurse is appropriate?

"He is NPO until the speech-language pathologist performs a swallowing evaluation."

A client is scheduled for a percutaneous endoscopic lumbar discectomy. Which statement by the client indicates a need for further teaching?

"I'll be in the hospital for 2 to 3 days."

The nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions would the nurse include in this client's plan of care? (Select all that apply.)

Have suction equipment with an airway at the bedside. Have oxygen administration set at the bedside. Ensure that the client has IV access.

The nurse assesses a client who is experiencing a common migraine without an aura. Which assessment finding(s) would the nurse expect? (Select all that apply.)

Headache lasting up to 72 hours Unilateral and pulsating headache Pain worsens with physical activities Photophobia

The nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate for migraine headaches. Which condition would alert the nurse to withhold the medication and contact the primary health care provider?

Heart disease

The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first?

Client who has a temperature of 102° F (38.9° C)

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would the nurse correlate with neurogenic shock? (Select all that apply.)

Heart rate of 34 beats/min Urine output less than 30 mL/hr Decreased level of consciousness

A nurse assesses a client who is recovering from the implantation of a vagal nerve-stimulation device. For which signs and symptoms would the nurse assess as common complications of this procedure? (Select all that apply.)

Hoarseness Dysphagia

A nurse assesses a patient who is recovering from a lumbar puncture (LP). Which complication of this procedure would alert the nurse to urgently contact the primary health care provider?

Nausea and vomiting

A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson disease. Which statement would the nurse include as part of this teaching?

"Allow the client to be as independent as possible with activities."

13. A nurse is teaching a client with cerebellar function impairment. Which statement would the nurse include in this client's discharge teaching?

"Ask a friend to drive you to your follow-up appointments."

A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching?

"Avoid overexertion, stress, and extreme temperature if possible."

The nurse is caring for a client who has Alzheimer disease. The client's wife states, "I am having trouble managing his behaviors at home." Which questions would the nurse ask to assess potential causes of the client's behavior problems? (Select all that apply.)

"Does your husband bathe and dress himself independently?" "Does his behavior become worse around large crowds?" "Do you have a clock and calendar in the bedroom and kitchen?"

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the his understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of his injury? (Select all that apply.)

"Ejaculation may not be as predictable as before." "I may urinate with ejaculation but this will not cause infection." "I should be able to have an erection with stimulation."

A nurse cares for a client with a spinal cord injury. With which interprofessional health team member would the nurse collaborate to assist the client with activities of daily living?

Occupational therapist

15. A nurse prepares a client for lumbar puncture (LP). Which assessment finding would alert the nurse to contact the primary health care provider?

Shingles infection on the client's back

A nurse assesses clients at a community center. Which client is at greatest risk for low back pain?

A 65-year-old female with osteoarthritis.

A client is admitted with a traumatic brain injury. What is the nurse's priority assessment?

Airway and breathing assessment

A client is admitted with a diagnosis of cerebellar stroke. What intervention is most appropriate to include on the client's plan of care?

Ambulate only with a gait belt.

A nurse assesses a client who is recovering from an open anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the primary health care provider?

Auscultated stridor

A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse's first action?

Discontinue the infusion of the drug.

The nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure?

d. Tonic-clonic

A nurse assesses the health history of a client who is prescribed ziconotide for chronic low back pain. Which assessment question would the nurse ask?

"Have you been diagnosed with a mental health problem?"

The nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed with Alzheimer disease. Which statement by the caregiver indicates a need for further teaching?

"I will avoid communicating with the client to prevent agitation."

The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse's teaching?

"I will remind the client frequently to not get out of bed without help."

The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" What is the nurse's best response?

"Engage the client in scheduled activities throughout the day."

A nurse teaches the spouse of a client who has Alzheimer disease. Which statements should the nurse include in this teaching related to caregiver stress reduction? (Select all that apply.)

"Establish advanced directives early." "Set aside time each day to be away from the client." "Use discipline to correct inappropriate behaviors."

After teaching a client who is diagnosed with new-onset epilepsy and prescribed phenytoin, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?

"Even when my seizures stop, I will continue to take this drug."

The nurse teaches an 80-year-old client with diminished peripheral sensation. Which statement would the nurse include in this client's teaching?

"Look at the placement of your feet when walking."

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which statement(s) would the nurse include in this education? (Select all that apply.)

"Participate in an exercise program to strengthen back muscles." "Wear flat instead of high-heeled shoes to work each day." "Avoid prolonged standing or sitting, including driving."

The primary health care provider prescribes donepezil for a client diagnosed with early-stage Alzheimer disease. What teaching about this drug will the nurse provide for the client's family caregiver?

"Report any client dizziness or falls because the drug can cause bradycardia."

A nurse is teaching a client who experiences migraine headaches and is prescribed propranolol. Which statement would the nurse include in this client's teaching?

"Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches."

14. Which statement would the nurse include when teaching the assistive personnel (AP) about how to care for a client with cranial nerve II impairment?

"Tell the client where food items are on the breakfast tray."

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I don't understand the need for rehabilitation; the paralysis will not go away and it will not get better." How would the nurse respond?

"The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability."

A nurse teaches a client who is recovering from an open traditional cervical spinal fusion. Which statement would the nurse include in this client's postoperative instructions?

"Wear your neck brace whenever you are out of bed."

The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke?

Client has a long history of atrial fibrillation.

2. A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which nursing action is most appropriate to manage this client's dementia?

Ensure a structured and consistent environment.

The nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first?

Evaluate respiratory status.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate?

Explain that personality changes are common following brain injuries.

The nurse is caring for a 60-year-old female client who sustained a thoracic spinal cord injury 10 years ago. For which potential complication will the nurse assess during this client's care?

Fracture

A nurse assesses a client with a brain tumor. Which newly identified assessment findings would alert the nurse to urgently communicate with the primary health care provider? (Select all that apply.)

Glasgow Coma Scale score of 8 Decerebrate posturing Decreasing level of consciousness

The nurse is teaching a group of college students about the importance of preventing meningitis. Which health promotion activity is the most appropriate for preventing this disease?

Obtaining the recommended meningitis vaccination and boosters

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next?

Palpate the bladder for distention.

The nurse is collaborating with the occupational therapist to assist a client with a complete cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid would be most appropriate for the client to meet this outcome?

Sliding board

The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first?

Turn the client's head to the side.