NS Final.

A patient has recently suffered a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely? a. Use a straw b. Tuck chin when swallowing c. Take a sip of liquid with each bite d. Turn head to the left

b. Tuck chin when swallowing

An 83-year-old patient has had a stroke. He is right-handed and has a history of hypertension and "little" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him: a. from the right side. b. from the left side. c. from the center. d. from either side.

b. from the left side.

After a stroke, a 75-year-old client is admitted to a health care facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which action is a priority for this client?

Elevating the head of the bed to 30 degrees

What should the nurse do when assisting a blind person to walk in an unfamiliar hospital environment? (Select all that apply)

Encourage the patient to ask for verbal cues Place patient hand on nurse's shoulder or elbow Describe the surroundings

An elderly patient is being discharged after having a cataract removed during same-day surgery. The nurse's priority is to assess the patient for which ability?

A. Ability to administer eyedrops postprocedure

A Tensilon test is performed on a client with suspected myasthenia gravis. Which finding constitutes a positive result?

An increase in muscle strength

The nurse is preparing to discharge a patient with myasthenia gravis. What self-management activities should the nurse include in the discharge education to prevent exacerbations of myasthenia gravis? Select all that apply.

Avoid heat Plan rest periods

A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client's personal care items:

B. Within the client's reach on the right side Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is not there. The client does not look at the paralyzed limb when moving about. Unilateral neglect results in increased risk for injury. It is possible for the client to relearn to look for and to move the affected limb(s). Therefore in this condition the client's personal care items are placed within the client's reach on the right side. Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This reduces client frustration and aids in ensuring client safety because the client does not have to strain and reach for needed items. The nurse adapts the client's environment to the deficit by focusing on the client's unaffected side and by placing the client's personal care items on the affected side within reach. Placing items out of the client's reach presents a risk of injury.

Which three symptoms are a characteristic of Cushing's triad associated with increased ICP?

Bradycardia hypertension widening pulse pressure

The nurse recognizes the presence of Cushing's triad in the patient with which vitals? A. Increase pulse, irregular respirations, increased BP B. Decreased pulse, increased respirations, decreased systolic BP C. Decreased pulse, irregular respiration, widened pulse pressure D. Increased pulse, decreased respiration, widened pulse pressure

C. Decreased pulse, irregular respiration, widened pulse pressure

What factors must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired? (Select all that apply.)

Cultural beliefs Values Habits

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? A) Administering zolpidem tartrate (Ambien) B) Assessing laboratory test results as ordered C) Placing the client in Trendelenburg's position D) Monitoring the patency of an indwelling urinary catheter

D) Monitoring the latency of an indwelling urinary catheter. Rationale. A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.

cannot see things in the distance

Myopia

A client who experienced a severe stroke develops a fever and a cough that produces thick, yellow sputum. A nurse observes sediment in the client's urine in the indwelling urinary catheter tubing. Based on these findings, which action should the nurse take?

Notify a physician of the findings.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?

Notify physician Hesi answer: Alternatively patch one eye every 2 hours.

A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?

Elevate the head of the bed 15 to 30 degrees. Rationale. This will facilitate venous drainage and avoid jugular compression

1The nurse notices that the patient must hold the newspaper at arm's length and squint to read. The nurse understands that this finding is consistent with which eye problem?

Hyperopia

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern Rationale. Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.

refers to the hardening of the ciliary bodies of the eyes ( aging process)

Prespyobia

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?

Suction machine with catheters

When caring for a client with head trauma, the nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do?

Test the nasal drainage for glucose.

How would the nurse instruct a patient with Parkinson disease to improve activity level?

To walk with hands clasped behind back to help balance The patient with Parkinson disease can improve the activity level by sleeping on a firm Mattress without a pillow to prevent spinal curvature, hold hands clasped behind to keep better balance , and keep the arms from hanging stiffy at the side, walk with a lifting of the feet to avoid tripping and "freezing"

What is a common mistake that hinders communication when communicating with the hearing impaired? a. Overaccentuating words b. Facing the patient when speaking c. Speaking in conversational tones d. Speaking into the ear with the hearing aid

a. Overaccentuating words

Why would the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp? a. The lamp can cause cataracts. b. The lamp can cause presbycusis. c. The lamp can cause keratitis. d. The lamp can cause ectropion.

a. The lamp can cause cataracts.

refers to a visual defect resulting from a warped lens or an irregular curvature of the cornea.

astigmatism

A client is diagnosed with trigeminal neuralgia (tic douloureux).What nursing intervention is most appropriate to include in this client's plan of care for preventing episodes of paroxysmal pain?

avoid care that involves touching the clients face

What is the priority nursing intervention in the postictal phase of a seizure? a. Reorient the client to time, person, and place. b. Determine the client's level of sleepiness. c. Assess the client's breathing pattern. d. Position the client comfortably.

c. Assess the client's breathing pattern. Rationale. A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

Which of the following techniques are necessary for safely feeding a hemiplegic patient? (Select all that apply.) a. Mixing liquids and solid foods together b. Taking the patient's dentures out to prevent choking c. Checking the affected side of mouth for food accumulation d. Offering small bites of food e. Elevating the patient to no more than 30 degrees f. Adding a thickening agent to liquids

c. Checking the affected side of mouth for food accumulation d. Offering small bites of food f. Adding a thickening agent to liquids

The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to: a. damaged tympanic membrane. b. protective buildup of cerumen. c. damage of the fine hair cells in the organ of Corti. d. rupture of the oval window.

c. damage of the fine hair cells in the organ of Corti. ( CONDUCTIVE HEARING LOSS)

What is the function of the CSF?

cushions the brain and spinal cord

How should the nurse advise a patient who has severe vertigo from labyrinthitis? a. Lean against a wall and not head forward until vertigo lessens. b. Bend at the waist and take several deep breaths. c. Drink an iced drink slowly.

d. Lie immobile and hold the head in one position until the vertigo lessens.

One of the housekeepers splashes a chemical in the eyes. What should be the first priority? a. Transport to a physician immediately b. Cover the eyes with a sterile gauze c. Irrigate with H2O for 5 minutes d.Irrigate with normal saline solution for 20 minutes

d.Irrigate with normal saline solution for 20 minutes

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:

demonstrate eyedrop instillation.

The nursing team begins developing a care plan for the stoke victim. When the nurse monitors the client's neurologic status, what finding is most suggestive that the client's intracranial pressure is increasing?

systolic pressure increases and diastolic pressure decreases * widening of BP

When documenting a seizure, what information is most important to include initially?

the duration of the seziure

The nurse advises a patient with myasthenia gravis (MG)

to perform physically demanding activities early in the day.