NUR-217 Medsurg Prep U questions

A client with infective endocarditis is admitted to the hospital. While obtaining a history, what should the nurse ask the client about? Select all that apply. Intravenous (IV) drug use Renal dialysis Prosthetic cardiac valves Nasal piercing Recent urinary tract infection

Intravenous (IV) drug use Renal dialysis Prosthetic cardiac valves Nasal piercing Recent urinary tract infection Explanation: Endocarditis infections are common among IV injection drug users; clients with debilitating disease or indwelling catheters; clients receiving hemodialysis or prolonged IV fluid or antibiotic therapy; clients with oral, nasal, or nipple body piercings; and, clients with prosthetic cardiac valves.

After a seizure, the nurse should place the patient in which of the following positions to prevent complications? A- Supine, to rest the muscles of the extremities B- High Fowler's, to prevent aspiration C- Side-lying, to facilitate drainage of oral secretions D- Semi-Fowler's, to promote breathing

Side-lying, to facilitate drainage of oral secretions Explanation: To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.

Which instruction should a nurse provide a client with a history of rheumatic fever before the client has any dental work done? To take prophylactic antibiotics To take aspirin To take steroids To avoid any kind of activity

To take prophylactic antibiotics Explanation: Clients with a history of rheumatic fever are susceptible to infective endocarditis and should be asked to take prophylactic antibiotics before any invasive procedure, including dental work. Steroids are prescribed to suppress the inflammatory response and aspirin to control the formation of blood clots around heart valves. Activities that require minimal activity are recommended to reduce the work of the myocardium and counteract the boredom of weeks of bed rest.

A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing? A- Insert oral airway B-Turn the client to the side C- Administer mannitol D- Place a cooling blanket on the client

Turn the client to the side Explanation: When a client is seizing, the nurse should turn the client to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. An oral airway should not be inserted while the client is actively seizing. An oral airway may be inserted during the aura phase. Anticonvulsants may be administered, but mannitol is an osmotic diuretic, not an anticonvulsant. Applying a cooling blanket while the client is actively seizing could cause harm to the client and is not indicated for seizure activity.

The nurse is providing discharge instructions to the client with acute post-streptococcal glomerulonephritis. Which statement by the client indicates a need for further teaching? "My intake of high sodium foods should be limited." "I should drink as much as possible to keep my kidneys working." "I should limit the amount of protein in my diet." "I should limit foods high in potassium in my diet, such as bananas."

"I should drink as much as possible to keep my kidneys working." Explanation: Dietary management of acute post-streptococcal glomerulonephritis includes restrictions of protein, sodium, potassium, and fluids.

The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is A- Change in level of consciousness B- Slowing of heart rate C- Elevation of systolic blood pressure D- Widening pulse pressure

Change in level of consciousness Explanation: The earliest sign of increasing ICP is a change in level of consciousness. Other early indicators are slowing of speech and delay in response to verbal suggestions. The other three choices are all parts of a clinical phenomenon known as the Cushing's response, which is a late sign of increasing ICP.

A change that occurs during chronic glomerulonephritis is termed hypophosphatemia. metabolic alkalosis. hypokalemia. anemia.

anemia. Explanation: Anemia, hyperkalemia, metabolic acidosis, and hyperphosphatemia occur during chronic glomerulonephritis.

What are contributing causes to pericarditis? Select all that apply. myocarditis cardiac surgery chest trauma tuberculosis common cold

cardiac surgery tuberculosis myocarditis chest trauma Explanation: Pericarditis usually is secondary to endocarditis, myocarditis, chest trauma, or MI (heart attack), or develops after cardiac surgery. The common cold is not a contributing cause of pericarditis.

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: A- hypothermia is indicative of malaria. B- hypothermia can cause death to the client. C- hypothermia is indicative of severe meningitis. D- shivering in hypothermia can increase ICP.

shivering in hypothermia can increase ICP. Explanation: Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure.

When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate? Cola-colored urine Pyuria Left upper quadrant pain Low blood pressure

Cola-colored urine Explanation: Cola-colored urine is a typical symptom of glomerulonephritis. Flank pain on the affected side, not left upper quadrant pain, would be present. Pyuria is a symptom of pyelonephritis, not glomerulonephritis. Blood pressure typically elevates in glomerulonephritis.

A client recovering from hepatitis B develops acute nephrotic syndrome. Which treatment will the nurse anticipate being prescribed for this client? Vancomycin Methylprednisolone Increase in sodium intake Low-carbohydrate diet

Methylprednisolone Explanation: Acute nephritic syndrome is a type of acute glomerulonephritis. The focus of management is to treat symptoms, preserve kidney function, and treat complications. Treatment may include corticosteroids such as methylprednisolone. Antibiotics such as vancomycin are used to treat bacterial infections. Hepatitis B is caused by a virus. Sodium would be restricted if the client has hypertension, edema, or heart failure. Carbohydrates should be ingested liberally to provide energy and reduce the catabolism of protein.

client is having a tonic-clonic seizure. What should the nurse do first? A- Restrain the client's arms and legs. B- Place a tongue blade in the client's mouth. C- Elevate the head of the bed. D- Take measures to prevent injury.

Take measures to prevent injury. Explanation: Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? A- unequal response B- constricted response C- rapid response D- equal response

unequal response Explanation: In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? A- 6 B- 12 C- 9 D- 3

3 Explanation: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68).

A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? 70 mm Hg 60 mm Hg 50 mm Hg 80 mm Hg

70 mm Hg Explanation: Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg (Hickey, 2009).

A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder? Nephrotic syndrome Chronic renal failure Acute glomerulonephritis Acute renal failure

Acute glomerulonephritis Explanation: Acute glomerulonephritis is also associated with varicella zoster virus, hepatitis B, and Epstein-Barr virus. Acute renal failure is associated with hypoperfusion to the kidney, parenchymal damage to the glomeruli or tubules, and obstruction at a point distal to the kidney. Chronic renal failure may be caused by systemic disease, hereditary lesions, toxic agents, infections, and medications. Nephrotic syndrome is caused by disorders such as chronic glomerulonephritis, systemic lupus erythematosus, multiple myeloma, and renal vein thrombosis.

A client with a history of rheumatic heart disease knows they are at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the client knows the importance of taking which of the following drugs? A-Enoxaparin B-Metoprolol C-Azathioprine D-Amoxicillin

Amoxicillin Explanation: Although rare, bacterial endocarditis may be life threatening. A key strategy is primary prevention in high-risk clients (i.e., those with rheumatic heart disease, mitral valve prolapse, or prosthetic heart valves). Antibiotic prophylaxis is recommended for high-risk clients immediately before and sometimes after certain procedures. Amoxicillin is the drug of choice. None of the other listed drugs is an antibiotic.

Which medication classification is used preoperatively to decrease the risk of postoperative seizures? A- Antianxiety B- Anticonvulsants C- Diuretics D- Corticosteroid

Anticonvulsants Explanation: Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the client with increased intracranial pressure.

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient? A- To assess visual acuity B- Access for intravenous (IV) fluids C- Visualization of a hemorrhage D- Aspiration of a brain abscess

Aspiration of a brain abscess Explanation: Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? A- Assess Glasgow Coma Scale. B- Assess vital signs. C- Assess pupils. D- Assess for a patent airway.

Assess for a patent airway. Explanation: A patient with altered LOC may be unable to protect his or her airway and therefore the priority nursing intervention should be to assess for a patent airway. The nurse should assess pupils, vital signs, and Glasgow Coma Scale, but only after ensuring the patient has a patent airway.

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient? A- Positioning to prevent complications B- Determination of the cause C- Maintenance of a patent airway D- Assessment of pupillary light reflexes

Maintenance of a patent airway Explanation: The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway.

A child is brought into the clinic with symptoms of edema and dark brown rusty urine. Which nursing assessment finding would best assist in determining the cause of this problem? Sore throat 2 weeks ago Protein elevation in the urine Elevation of blood pressure Red blood cells in the urine

Sore throat 2 weeks ago Explanation: Acute glomerulonephritis usually occurs as a result of bacterial infection such as seen with a beta-hemolytic streptococcal infection or impetigo. Red blood cells and protein found in the urine and elevated blood pressure are symptoms associated with glomerulonephritis.

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? A- Monitor vital signs. B- Manually restrain the extremities. C- Turn client to side-lying position. D- Insert an airway or bite block.

Turn client to side-lying position. Explanation: When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth. Turning the client also allows the tongue to fall forward opening the airway. More damage can occur if a bite block is inserted after the seizure has begun. Manually restraining extremities is not recommended. Attempting to take blood pressure is not recommended and pulse rate and respirations during the event will not be beneficial. Monitor vital signs during the postictal phase.

A client is diagnosed with pericarditis. What symptom will be the nurse's priority for treatment? denial fatigue anxiety acute pain

acute pain Explanation: Pain is the primary symptom of the client with pericarditis. Pain relief and the absence of complications are two major nursing goals. The client may have anxiety, fatigue, or denial, but these symptoms are not the nurse's priority for care.

Which nursing intervention would reduce cardiac workload in a client with myocarditis? Lower the client's head. Administer a prescribed antipyretic. Maintain the client on bed rest. Eliminate all phone calls and visitors.

Maintain the client on bed rest. Explanation: The nurse should maintain the client on bed rest to reduce cardiac workload and promote healing. The nurse would administer a prescribed antipyretic only if the client has a fever. The nurse elevates the client's head to promote maximal breathing potential. Treatment for myocarditis does not preclude allowing the client to have visitors or use the telephone.

While assessing a patient with pericarditis, the nurse cannot auscultate a friction rub. Which action should the nurse implement? Document that the pericarditis has resolved. Prepare to insert a unilateral chest tube. Ask the patient to lean forward and listen again. Notify the health care provider.

Ask the patient to lean forward and listen again. Explanation: The most characteristic sign of pericarditis is a creaky or scratchy friction rub heard most clearly at the left lower sternal border. Having the patient lean forward and to the left uses gravity to force the heart nearer to the chest wall, which allows the friction rub to be heard. These assessment data are not life-threatening and do not require a call to the health care provider. The nurse should try multiple times to auscultate the friction rub before deciding that the rub is gone. Chest tubes are not the treatment of choice for not hearing friction rubs.

client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first? A- Put a padded tongue blade into the client's mouth and restrain his extremities. B- Initiate the code team response. C- Record the type of seizure and the time that it occurred. D- Assist the client to the floor, in a side-lying position, and protect him with linens.

Assist the client to the floor, in a side-lying position, and protect him with linens. Explanation: The nurse should protect the client from injury by assisting him to the floor, in a side-lying position, and protect him from harm by padding the floor with bed linens. Initiating a response from the code team isn't necessary because seizures are self-limiting. As long as the client's airway is protected, his cardiopulmonary status isn't affected. The nurse shouldn't force anything into the client's mouth during a seizure; doing so may cause injury. Documenting seizure activity is important, but it doesn't take priority over client safety.

Which of the following occurs late in chronic glomerulonephritis? Peripheral neuropathy Stroke Seizure Nosebleed

Peripheral neuropathy Explanation: Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with or without a pericardial friction rub. The first indication of disease may be a sudden, severe nosebleed, a stroke, or a seizure.

What is a hallmark of the diagnosis of nephrotic syndrome? Hyperalbuminemia Proteinuria Hyponatremia Hypokalemia

Proteinuria Explanation: Proteinuria (predominantly albumin) exceeding 3.5 g per day is the hallmark of the diagnosis of nephrotic syndrome. Hypoalbuminemia, hypernatremia, and hyperkalemia may occur.

A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant? History of osteoporosis History of hyperparathyroidism Previous episode of acute pyelonephritis Recent history of streptococcal infection

Recent history of streptococcal infection Explanation: Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV). A history of hyperparathyroidism or osteoporosis would place the client at risk for developing renal calculi. A history of pyelonephritis would increase the client's risk for chronic pyelonephritis.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? A- Sleeping quietly after the seizure B- The client cried out before the seizure began. C- Seizure was 1 minute in duration including tonic-clonic activity. D- Seizure began at 1300 hours.

Seizure was 1 minute in duration including tonic-clonic activity. Explanation: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.

A nurse working at a pediatric clinic is teaching a group of parents. A parent asks the nurse if it is okay to let the young child recover from a sore throat naturally, rather than bringing the child to the clinic for diagnosis and treatment. What is the nurse's best response? A- "Health care providers tend to overtreat children with antibiotics so the child recovers quickly." B- "It may be streptococcal sore throat. Rheumatic heart disease can be prevented with early treatment." C- "It is fine to let the child recover naturally; it will save you time and money." D- "It is not a good idea to give antibiotics for every sore throat that your child has because of the overuse of antibiotics."

"It may be streptococcal sore throat. Rheumatic heart disease can be prevented with early treatment." Explanation: A sore throat may be streptococcal pharyngitis. Diagnosing and treating the sore throat can prevent rheumatic fever and, therefore, rheumatic heart disease. Letting children recover naturally can be dangerous if the sore throat is a streptococcal infection. The use of antibiotics is considered by each prescribing heath care provider. General statements about treatments are not helpful.

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? A- Jacksonian B- Generalized C- Absence D- Sensory

Generalized Explanation: A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.

A nurse and a nursing student are performing a physical assessment of a client with pericarditis. The client has an audible pericardial friction rub on auscultation. When leaving the room, the student asks the nurse what causes the sound. The nurse's best response is which of the following? A- "The lung surfaces lose their lubrication and rub against the myocardium with each heart beat." B- "The great vessels rub against the pericardium with each heart beat." C- "The layers of the heart become loose from each other and rub together with each heart beat." D- "The pericardial surfaces lose their lubricating fluid because of inflammation and rub against each other."

"The pericardial surfaces lose their lubricating fluid because of inflammation and rub against each other." Explanation: A pericardial friction rub occurs when the pericardial surfaces lose their lubricating fluid due to inflammation. The rub is audible on auscultation and is synchronous with the heartbeat. The layers of the heart never become loose from each other. The great vessels are not in contact with the inside of the pericardium, where the inflammation is located. The lungs have nothing to do with a pericardial friction rub.

nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? A- Provide sensory stimulation. B- Encourage coughing and deep breathing. C- Administer stool softeners. D- Position the client with the head turned toward the side of the brain tumor.

Administer stool softeners. Explanation: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP

Which of the following is a term used to describe excessive nitrogenous waste in the blood, as seen in acute glomerulonephritis? Proteinuria Bacteremia Azotemia Hematuria

Azotemia Explanation: The primary presenting features of acute glomerulonephritis are hematuria, edema, azotemia (excessive nitrogenous wastes in the blood), and proteinuria (>3 to 5 g/day). Bacteremia is excessive bacteria in the blood.

client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? A- Irregular breathing pattern B- Declining level of consciousness (LOC) C- Involuntary posturing D- Pupillary asymmetry

Declining level of consciousness (LOC) Explanation: With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

A client who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse should discuss the importance of antibiotic prophylaxis prior to which of the following? A-Dental procedures B- Future hospital admissions C- Live vaccinations D-Exposure to immunocompromised individuals

Dental procedures Explanation: Following mechanical valve replacement, antibiotic prophylaxis is necessary before dental procedures involving manipulation of gingival tissue, the periapical area of the teeth or perforation of the oral mucosa (not including routine anesthetic injections, placement of orthodontic brackets, or loss of deciduous teeth). There are no current recommendations around antibiotic prophylaxis prior to vaccination, future hospital admissions, or exposure to people who are immunosuppressed.

A client is experiencing symptoms of infective endocarditis. Which tests will the nurse expect to be prescribed for this client? Select all that apply. Ejection fraction Echocardiogram Two blood cultures White blood cell count Erythrocyte sedimentation rate

Echocardiogram Two blood cultures White blood cell count Erythrocyte sedimentation rate Explanation: Infective endocarditis is a microbial infection of the endothelial surface of the heart. A definitive diagnosis is made when a microorganism is found in two separate blood cultures and there is evidence of vegetation on imaging of the heart or echocardiogram. Negative blood cultures do not definitely rule out infective endocarditis. Clients may have elevated white blood cell (WBC) counts. In addition, clients may have an elevated erythrocyte sedimentation rate (ESR). Ejection fraction is not used to diagnose infective endocarditis.

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)? A- Maintain a well-lit room. B- Suction the airway every hour and as needed. C- Turn the client every 2 hours. D- Elevate the head of the bed 30 degrees.

Elevate the head of the bed 30 degrees Explanation: To facilitate venous drainage and avoid jugular compression, the nurse should generally elevate the head of the bed 30 degrees. Clients with increased ICP poorly tolerate suctioning and should not be suctioned on a regular basis. Turning the client from side to side increases the risk of jugular compression and increases in ICP, so turning and changing positions should be avoided. The room should be kept quiet and dimly lit.

A client admitted with nephrotic syndrome is being cared for on the medical unit. When writing this client's care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? A- Risk for injury related to altered thought processes B- Excess fluid volume related to generalized edema C- Constipation related to immobility D- Hyperthermia related to the inflammatory process

Excess fluid volume related to generalized edema Explanation: The major clinical manifestation of nephrotic syndrome is edema, so the appropriate nursing diagnosis is "Excess fluid volume related to generalized edema." Edema is usually soft, pitting, and commonly occurs around the eyes, in dependent areas, and in the abdomen.

An adult client with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. The medical history reveals diabetes mellitus, hypertension, and pernicious anemia. The client underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. What history finding is a major risk factor for infective endocarditis? History of diabetes mellitus Anemia Age History of aortic valve replacement

History of aortic valve replacement Explanation: A heart valve prosthesis such as an aortic valve replacement is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although age and a history of diabetes mellitus or anemia may predispose a person to cardiovascular disease, they aren't major risk factors for infective endocarditis.

A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure? A- Keep the client on one side. B- Help the client sit up. C- Place a cooling blanket beneath the client. D- Pry the client's mouth open to allow a patent airway.

Keep the client on one side Explanation: The nurse will need to keep the client on one side to prevent aspiration. Make sure the airway is patent. On awakening, reorient the client to the environment. If the client is confused or wandering, guide the client gently to a bed or chair. If the client becomes agitated after a seizure (postictal), stay a distance away, but close enough to prevent injury until the client is fully aware. The client does not need a cooling blanket after a seizure. The client's temperature should not be elevated from the seizure. The nurse should not pry the client's mouth open after a seizure so that the airway remains open.

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? A- Assessment of pupillary light reflexes B- Determination of the cause C- Positioning to prevent complications D- Maintenance of a patent airway

Maintenance of a patent airway Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? A- Urea B- Isosorbide C- Mannitol D- Glycerin

Mannitol Explanation: If signs and symptoms of increased ICP occur, efforts to decrease the ICP are initiated: alignment of the head in a neutral position without flexion to promote venous drainage, elevation of the head of the bed to 30 degrees (when prescribed), administration of mannitol (an osmotic diuretic), and possible administration of pharmacologic paralyzing agents.

The client the nurse is caring for experiences a seizure. What would be a priority nursing action? A- Insert a tongue blade between the teeth. B- Restrain the client during the seizure. C- Protect the client from injury. D- Suction the mouth during the convulsion.

Protect the client from injury Explanation: The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure.

The nurse is reviewing a patient's laboratory results. What findings does the nurse assess that are consistent with acute glomerulonephritis? Select all that apply. White blood cell casts in the urine Proteinuria Polyuria Hemoglobin of 12.8 g/dL Red blood cells in the urine

Red blood cells in the urine Proteinuria Explanation: The primary presenting features of an acute glomerular inflammation are hematuria, edema, azotemia (an abnormal concentration of nitrogenous wastes in the blood), and proteinuria (excess protein in the urine). The urine may appear cola colored because of red blood cells (RBCs) and protein plugs or casts; RBC casts may be present, indicating glomerular injury. Acute glomerulonephritis does not present with white blood cell (WBC) casts.

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant? Croup Rheumatic fever Medullary sponge kidney Severe staphylococcal infection

Rheumatic fever Explanation: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, may eventually lead to hypertension but doesn't damage heart structures.

A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? A- Menarche B- Streptococcal infection C- Psychosocial stress D- Hypersensitivity to an immunization

Streptococcal infection Explanation: Postinfectious causes of postinfectious glomerular disease are group A beta-hemolytic streptococcal infection of the throat that precedes the onset of glomerulonephritis by 2 to 3 weeks. Menarche, stress, and hypersensitivity are not typical causes.

A client has a history of rheumatic fever as a child. Which instructions should be provided before the client has any dental work done? Avoid any kind of activities. Take aspirin. Take prophylactic antibiotics. Take steroids.

Take prophylactic antibiotics. Explanation: Clients with a history of rheumatic fever are susceptible to infective endocarditis and should be asked to take prophylactic antibiotics before any invasive procedure, including dental work. Steroids are used to suppress the inflammatory response. Aspirin is an anticoagulant and used to control the formation of blood clots around heart valves. Many clients cannot appreciate the danger of a disease without seeing external signs of the damage. The nurse gently but firmly reminds the client to limit activity.

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? A- Provide oxygen or anticonvulsants, whichever is available B- Place a cooling blanket beneath the client C- Suction the client's mouth and pharynx D- Turn the client to the side during a seizure and do not restrain movements

Turn the client to the side during a seizure and do not restrain movements When a client is in a seizure, the nurse should turn the client to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. The nurse should suction the mouth and pharynx after a seizure has occurred, not during the seizure. Anticonvulsants may be administered to reduce the chances of seizure. Oxygen should not be given to clients with seizures. Clients with respiratory distress are given oxygen. Finally, a cooling blanket is placed beneath the client when hyperthermia occurs, not a seizure.

The nurse is assessing a client suspected of having developed acute glomerulonephritis. Which clinical manifestation assessed by the nurse correlate with this suspicion? A-Precipitous decrease in serum creatinine levels B-Urine positive for blood C-Hypotension unresolved by fluid administration D-Decrease in blood urea nitrogen levels

Urine positive for blood Explanation: In acute glomerulonephritis, the kidneys become large, edematous, and congested. All renal tissues, including the glomeruli, tubules, and blood vessels, are affected to varying degrees. The primary presenting feature of acute glomerulonephritis is hematuria (blood in the urine), which may be microscopic (identifiable through microscopic examination) or macroscopic or gross (visible to the eye). Proteinuria, primarily albumin, which is present, is due to increased permeability of the glomerular membrane. Blood urea nitrogen (BUN) and serum creatinine levels may rise as urine output drops. Some degree of edema and hypertension is noted in most clients.

client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: A- hold the client's arm still to keep him from hitting anything. B- carefully move the client to a flat surface and turn him on his side. C- allow the client to remain in the chair but move all objects out of his way. D- place an oral airway in the client's mouth to maintain an open airway.

carefully move the client to a flat surface and turn him on his side. Explanation: When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat non-elevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.

The initial sign of increasing intracranial pressure (ICP) includes A- vomiting. B- sore throat. C- decreased level of consciousness. D- herniation.

decreased level of consciousness. Explanation: The initial signs of increasing ICP include decreased level of consciousness and focal motor deficits. If ICP is not controlled, the uncus of the temporal lobe may be herniated through the tentorium, causing pressure on the brain stem. Vomiting and sore throat are not initial signs of increasing ICP.

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should: A- place the client on his back, remove dangerous objects, and insert a bite block. B- place the client on his side, remove dangerous objects, and protect his head. C- place the client on his back, remove dangerous objects, and hold down his arms. D- place the client on his side, remove dangerous objects, and insert a bite block.

place the client on his side, remove dangerous objects, and protect his head. Explanation: During the active seizure phase, the nurse should initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration. Placing the client on his back and holding down the arms could cause injury to the client and the nurse.

A client has been diagnosed with acute glomerulonephritis. This condition causes: No option is correct. polyuria. proteinuria. pyuria.

proteinuria. Explanation: The disruption of membrane permeability causes red blood cells (RBCs) and protein molecules to filter from the glomeruli into Bowman's capsule and eventually become lost in the urine. Pyuria is pus in the urine. Polyuria is an increased volume of urine voided

A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because A- hypothermia is indicative of severe meningitis. B- shivering in hypothermia can increase ICP. C- hypothermia can cause death. D- hypothermia is indicative of malaria.

shivering in hypothermia can increase ICP. The nurse should avoid hypothermia in a client with increased ICP because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure. Hypothermia in a client with ICP does not indicate malaria or meningitis and is not likely to cause death.

The nurse is providing discharge teaching to a client with recurrent endocarditis. What prevention strategies will be included with the teaching? Select all that apply. A- report recurrent fever lasting longer than 7 days to the health care provider B- use a toothpick to keep food from accumulating in the mouth C- body piercing can be done in a clean area D- notify dentist of the history of endocarditis with any planned dental procedures E- use a nail clipper for fingernail care

use a nail clipper for fingernail care report recurrent fever lasting longer than 7 days to the health care provider notify dentist of the history of endocarditis with any planned dental procedures Explanation: The client at high risk for endocarditis should report recurrent fever lasting longer than 7 days to the health care provider, avoid nail biting, and notify the dentist of the history of endocarditis before any planned dental procedures. Body piercing and using toothpicks can provide an entry for infection for high-risk clients.