NC3 Exam 2

A home health nurse is reinforcing coping strategies with the family caregiver of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching? (Select all that apply) 1.) Actions to reduce stress 2.) Identification of a social support system 3.) Referral to available community resources 4.) Instruction on client medication administration 5.) Expected physiological changes of the disease

1,2,3,5

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? A: Assess the client's airway patency. B: Place a tongue depressor in the client's mouth C: Remove objects from the client's mouth D: Place the client in a side-lying position E: Restrain the client

A, C, D

A nurse is teaching a client who has MS about a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? A. "Do not take antihistamines with this medication." B. "Take the medication on an empty stomach." C. "Stop taking the medication immediately for a headache." D. "Expect to develop diarrhea initially."

A. "Do not take antihistamines with this medication." Antihistamines will intensity the depressant effects of baclofen.

A nurse is caring for a child that is having a tonic-clonic seizure and vomiting. Which of the following is the priority nursing action? A. Place a pillow under the child's head B. Position the child side-lying. C. Loosen restrictive clothing. D. Clear the area of hazards

B. Position the child side-lying This is the priority due to the chance of aspirating from vomiting

The nurse in the ED is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenia crisis? A. Developing a respiratory infection B. Taking too much prescribed medication C. Diet high in protein D. Not enough exercise

A. Developing a respiratory infection This is the most common triggers of a crisis.

A nurse is caring for a client at a rehab center 3 weeks after a CVA. Because the clients CVA affected the left side of the brain, which of the following goals should the nurse anticipate including in the client's rehab program? A: Establish the ability to communicate effectively. B. Have a regular, formed stool at least every other day. C. Learn to control impulsive behavior D. Improve left-side motor function

A: Establish the ability to communicate effectively. Left side is usually dominant for language. Nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? A: poor impulse control B: Unable to discriminate words and letters C: Deficits in the right visual field D: Deficits in the right hearing

A: Poor impulse control

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenia crisis. Which of the following interventions should the nurse take? A: Prepare the client for mechanical ventilation B: Administer an anticholinesterase medication C: Instruct the client to perform the pursed lip breathing D: Prepare to administer a vasoconstrictor.

A: Prepare the client for mechanical ventilation At risk for loss of adequate respiratory function

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide? A: Phenytoin turns urine blue B: Alcohol increases the chance of phenytoin toxicity C: Avoid flossing the teeth to prevent gum irritation D: Take an antacid with the medication if indigestion occurs

B: Alcohol increases the chance of phenytoin toxicity

A nurse is caring for a client who is at 6 weeks of gestation and has pneumonia. While the nurse is obtaining the client's history, the client tells the nurse that she takes the herb feverfew for migraine headaches. Which of the following actions should the nurse take?? A: Tell the client that she should take an over-the-counter analgesic instead. B: Explain to the client that she should not take this herb while she is pregnant C: Ask the client why she would take a herb during pregnancy. D: Suggest that the client ask her herbalist within the next few weeks about taking it while pregnant.

B: Explain to the client that she should not take this herb while she is pregnant This herb interferes with platelet action and can cause bleeding!!

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's Vital signs are as follows; blood pressure 198/110 mmHg, pulse of 82min, respirations of 24/min, and a temp of 100.8F. Which of the following neurologic disorders should the nurse suspect? A: Transient Ischemic Attack (TIA) B: Hemorrhagic Stroke C: Thrombotic Stroke D: Embolic Stroke

B: Hemorrhagic Stroke A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including sudden onset of a sever headache, a decrease in the level of consciousness, and seizures.

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? A: Gradual onset of several hours B: Manifestations preceded by a severe headache C: Maintains consciousness D: History of neurologic deficits lasting less than 1 hr

B: Manifestations preceded by a severe headache

A nurse is preparing to administer PO medications to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication? A. Have the client empty his bladder B. Put up the side rails on the client's bed C. Ask the client to take a few sips of water. D. Place the client in low Fowler's Position

C. Ask the client to take a few sips of water. Clients who have myasthenia gravis, an autoimmune disorder, have weakness to the muscles of the face and throat which increases risk for aspiration.

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? A: The client's ECG tracing shows irregular hear rate without P waves B: The client has an aPTT of 80 seconds C: The client experiences sudden weakness of one arm and leg. D: The client's urine output is cloudy and odorous.

C: The client experiences sudden weakness of one arm and leg. This can indicate client is at risk for a stroke!!

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain? A: The partner has placed locks at the top of the doors leading to the outside B: The partner has hired a house cleaner C: The partner has lost 20 lb in the past 2 months D: The partner redirects the client when the client is frustrated.

C: The partner has lost 20lb in the past 2 months

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? A: Pruitius B: Hypertension C: Bradykinesia D: Xerostomia

C: Bradykinesia or difficulty moving

A nurse is caring for an adolescent client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the client's parent is the nurse's priority? A: "He take a 2-hour nap every day after school" B: "He says he feels sick to his stomach after taking this medication" C: "He has so many new bruises on his body." D: "He says his mouth is always dry."

C: "He has so many new bruises on his body."

A nurse is teaching a client who has a new prescription for sumatriptan tablets to treat migraine headaches. Which of the following instructions should the nurse include? A: "Take daily to prevent headaches" B: "Chew tablet well before swallowing" C: "Report swelling of eyelids after dosage." D: "Repeat dose in 1 hour for unrelieved headache."

C: "Report swelling of eyelids after dosage."

A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include? A: "take this medications daily to prevent headaches" B: "Activate the patch 30 minutes after application" C: "Use contraception while taking this medication" D: "You can bathe with the patch in place."

C: "Use contraception while taking this medication"

A nurse is caring for an adolescent client who is receiving carbamazepine (Tegretol) for partial seizure disorder. Which of the following statements by the client's parent should indicate to the nurse an immediate need for further evaluation? A: "He takes a 2-hour nap every day after school" B: "Sometimes, it seems like he is so out of it when I speak to him." C: "We have had to have his glasses changed three times in the last 6 months." D: "The rash he had seems to have gone away after I used the hydrocortisone cream."

C: "We have had to have his glasses changed three times in the last 6 months." Toxic levels of carbamazepine can cause diplopia/double vision, profound headaches, and vertigo. The increased levels impact secretion of ADH.

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?? A: Provide a nonskid mad to alleviate plate movement B: Encourage the client to use his right hand when feeding himself. C: Remind the client to look for food on the left side of the tray. D: Encourage the use of the wide grip utensils.

C: Remind the client to look for food on the left side of the tray.

A nuse is caring for a client who has parkinson's disease and is taking diphenhydramine 25mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see? A: Delay in disease progression B: Improved bladder function C: Relief of depression D: Decreased tremors

D. Decreased tremors Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty walking, and problems with balance and coordination. Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may be helpful in controlling tremors in the early stage of the disease

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?? A: "Wear an eye patch on the right eye at all times." B: "Plan to relax in a hot tub spa each day." C: "Engage in a vigorous exercise program." D: "Implement a schedule to include periods of rest."

D: "Implement a schedule to include periods of rest."

A family member is instructed by a nurse on the interventions for safe swallowing for a client who has residual effects from a stroke. Which of the following concepts are most important for the family members to understand? A: Offer mouth care before meals B: Place food in the unaffected side of the mouth C: Encourage the client to take small bites and chew food thoroughly. D: Place the client in the upright positions to facilitate swallowing.

D: Place the client in the upright position to facilitate swallowing. The greatest risk for this client is injury from aspiration.