NCA2- Exam 3
A nurse cares for a patient who has obstructive jaundice. The patient asks, "Why is my skin so itchy?" How would the nurse respond?
"Bile salts accumulate in the skin and cause the itching."
A nurse cares for a patient who has chronic cirrhosis from substance abuse. The patient states, "All of my family hates me." How would the nurse respond?
"I will help you identify a support system."
As an alternative to "serial sevens" a nurse would ask the patient to
Spell "world" backwards.
Part of the Folstein's mini-mental status exam is called "serial sevens". Correctly complete the sequence of five answers beginning with "100-93..."
86-79-72;
A nurse is teaching a community group about preventing hearing loss. What instruction is best?
Always wear a bicycle helmet.
After a stroke, a patient has ataxia. What intervention is most appropriate to include on the patient's plan of care?
Ambulate only with a gait belt.
The Glasgow Coma Scale assesses changes in the level of conciousness by scoring:
Best eye response (opening); Best Verbal respnse; Best Motor response
A patient with a stroke is being evaluated for fibrinolytic therapy. What information from the patient or family is most important for the nurse to obtain?
Time of symptom onset
Prior to assisting the gastroenterologist in performing a paracentesis on a patient with ascites, it is important to:
weigh the patient. obtain informed consent. make sure the patient voids prior to prcedure. get a full set of vitals before and after the procedure. teach the patient about the procedure and what to expect post procedure
Once the patient suspected of having a stroke reaches the Emergency Department, the patient would ideally undergo a CT of the head within 3 hours of the event to determine:
whether this stroke is thrombotic, embolic or hemorrhagic;
A patient does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best?
"Because eye pressure was too high, the tissue died."
A nurse cares for a patient who is prescribed lactulose (Heptalac). The patient states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond?
"Diarrhea is expected; that's how your body gets rid of ammonia."
A nurse cares for a patient who is recovering from laparoscopic cholecystectomy surgery. The patient reports pain in the shoulder blades. How would the nurse respond?
"Ambulating in the hallway twice a day will help."
If you suspect a patient in your clinic is having a stroke you would:
Ask the individual to SMILE. Ask him or her to RAISE BOTH ARMS Ask him or her to Ask the person to SPEAK A SIMPLE SENTENCE
A patient has mastoiditis and is prescribed antibiotics. What instruction by the nurse is most important for this patient?
Immediately report headache or stiff neck.
A patient with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority patient problem?
Inadequate airway
A student nurse is preparing morning medications for a patient who had a stroke. The student plans to hold the docusate sodium (Colace) because the patient had a large stool earlier. What action by the supervising nurse is best?
Inform the student that the docusate should be given.
A nurse cares for a patient with hepatic portal-systemic encephalopathy (PSE). The patient is thin and cachectic in appearance, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond?
"Less protein in the diet will help prevent confusion associated with liver failure."
A patient with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best?
"MG is an autoimmune problem in which nerves do not cause muscles to contract."
A nurse cares for a patient with hepatitis C. The patient's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How would the nurse respond?
"This type of Viral hepatitis is not spread through casual contact."
A patient in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000/mm 3 (8 × 10 9/L), magnesium 0.8 mEq/L (0.4 mmol/L), and sodium 138 mEq/L (138 mmol/L). What action by the nurse is best?
Instruct the patient on a magnesium supplement.
An older patient has decided to give up driving due to cataracts. What assessment information is most important to collect?
Knowledge about surgical options Presence of family support
An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate?
Assess for cerumen buildup.
A nurse cares for a patient who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. What action would the nurse take first?
Assess the patient for airway patency.
An older patient is hospitalized with Guillain-Barré syndrome. A family member tells the nurse that the patient is restless and seems confused. What action by the nurse is best?
Assess the patient's oxygen saturation.
A nurse cares for a patient who is scheduled for a paracentesis. Which intervention would the nurse delegate to an unlicensed assistive personnel (UAP)?
Assist the patient to void before the procedure.
A patient in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The patient's mental status is deteriorating. What action by the nurse is most appropriate?
Attempt to find the family to sign a consent.
A score of 9-12 0n the Glasgow Coma scale indicates:
Moderate head injury
The nurse is administering eyedrops to a client with an infection in the right eye. The drops go in both eyes, and two different bottles are used to administer the drops. The nurse accidentally uses the left eye bottle for the right eye. What action by the nurse is best?
Obtain a new bottle of eyedrops.
A patient is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority?
Respiratory system
You have been assigned a patient who was just admitted through ED. She is complaining of severe episodic pain radiating to her right side and shoulder. You are aware that pancreatitis can cause epigastric pain radiating to the left flank and left shoulder. Judging by her symptoms, you suspect this patient is more likely suffering from:
cholecystitis.
Risk factors for Parkinson's disease include
male gender; genetic predisposition; exposure to pesticides and chemical solvents, especially in the home; chronic use of antipsychotic medications
A patient with obstruction of the biliary system by gallstones (Cholelithiasis) has used the bathroom. Findings consistent with the patient's condition would be:
Clay colored stools and very dark urine.
A patient with Ménière's disease is in the hospital when the patient has an attack of vertigo. What action by the nurse takes priority?
Place the patient in bed with the upper side rails up.
A nurse cares for a patient who has cirrhosis of the liver. What action would the nurse take to decrease the presence of ascites?
Provide a low-sodium diet.
The nurse learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse understands that this causes what?
Slowed nerve impulse transmission
Upon entering a patient's room, the nurse finds that the patient can be aroused only by vigorous and continuous stimulation or strong auditory/visual stimulii. The nurse documents this response as :
Somnolent;
A nurse cares for a patient with acute pancreatitis. The patient states, "I am hungry." How would the nurse reply?
"Have you passed any flatus or moved your bowels?"
A patient with homonymous hemianopsia ( loss of the same visual field in both eyes) should be taught:
Turn their head (scan) toward the affected side when eating and ambulating;
A patient has external otitis. On what comfort measure does the nurse instruct the patient?
Use of a heating pad to the ear
To assure that the site clots and avoid post-procedure headache, the nurse includes in pre-procedure teaching for the patient undergoing Lumbar Puncture that the patient should:
remain flat in bed for 3-24 hours post procedure.
The nurse reads on a client's chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis?
Bulging eyes
In order to determine whether or not the patient has a brain tumor, the patient is scheduled for a PET scan. Pre- procedure teaching by the nurse should include:
Be aware that the patient's head will be restrained; Be aware the patient's blood sugar may be affected; Be aware that, if results indicate, a CT scan is likely to follow the PET scan in order to more precisely determine the location of the abnormality;
You are admitting a 50 year old patient to your clinic. He states that he has recently been diagnosed with Amyotropic Lateral Sclerosis..Given his age, one question you might ask him is:
Did you serve in the military during the gulf war?
An examination of the biliary ducts, gall bladder, liver and pancreas via an orally inserted endoscope is called:
ERCP (endoscopic retrograde cholangiopancreatography )
In order to decrease aspiration potential for patients with stroke and other neuromuscular disorders, the nurse should:
Enter a consult to speech therapy for swallowing studies; remind the patient to consciously flex their head forward when swallowing; review the tray to make sure a dysphagia diet has been ordered;
Pupils equally round & reactive to light and accommodation PERRLA is a "normal" finding during neuro checks. The nurse would assess accommodation by:
Have the patient to focus on an object at 2 to 3 feet and then to focus on the object at 6 to 8 inches;
A patient is taking timolol (Timoptic) eyedrops. The nurse assesses the patient's pulse at 48 beats/min. What action by the nurse is the priority?
Hold the eyedrops and notify the provider.
The nurse knows that a patient with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?
Liver
Your patient with liver failure secondary to hepatitis has been diagnosed with hepatic encephalopathy. During physical assessment you note that he has gross jerky movements especially when flexing his wrists. You heard the nurse during report describe this as "liver flap." You are aware that this is correctly called:
asterixis.