Adult Heath II exam 4
The nurse is planning the care for a client diagnosed with Parkinson's disease. Whichwould be a therapeutic goal of treatment for the disease process? A. The client will experience periods of akinesia throughout the day. B. The client will take the prescribed medications correctly. C. The client will be able to enjoy a family outing with the spouse. D. The client will be able to carry out activities of daily living.
ANS: D. The major goal of treating PD is tomaintain the ability to function. Clientsdiagnosed with PD experience slow,jerky movements and have difficultyperforming routine daily tasks.
problem associated with Parkinson's disease? 1. Emotional lability. 2. Depression. 3. Memory deficits. 4. Paranoia
ANS: 3
The client diagnosed with Parkinsons disease is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications?1. There will be fewer side effects with this combination than with carbidopa alone. 2. Dopamine D requires the presence of both of these medications to work. 3. Carbidopa makes more levodopa available to the brain. 4. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.
ANS: 3. Carbidopa enhances the effects oflevodopa by inhibiting decarboxylase inthe periphery, thereby making morelevodopa available to the centralnervous system. Sinemet is the mosteffective treatment for PD.
The nurse is admitting a client with the diagnosis of Parkinson's disease. Whichassessment data support this diagnosis? 1. Crackles in the upper lung fields and jugular vein distention. 2. Muscle weakness in the upper extremities and ptosis. 3. Exaggerated arm swinging and scanning speech. 4. Masklike facies and a shuffling gait.
ANS: 4. Masklike facies and a shuffling gait aretwo clinical manifestations of PD.
A client with cerebral metastasis suddenly experiences a seizure for which phenytoin 10 mg/kg intravenously is ordered as an initial loading dose. The client weighs 165 pounds. How many milligrams of phenytoin should the client receive?
ANS: 750
A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated?* A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr
ANS: A
A patient with Myasthenia Gravis has been admitted into the hospital with pneumonia. The nurse knows which of the following would be the most concerning issue for this patient? A) Respiratory Failure B) Fall risk C) Nerve compression D) The death of the neurons
ANS: A
Modafinil is a drug given for many conditions such as MS and ALS. What is this drug given for? A) Fatigue B) Muscle weakness C) Muscle spasms D) Neck righty
ANS: A
The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid? A) Washing his face B) Exposing his skin to sunlight C) Using artificial tears D) Drinking large amounts of fluids
ANS: A
The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid? A) Washing his face B) Exposing his skin to sunlight C) Using artificial tears D) Drinking large amounts of fluids
ANS: A
The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? A) Sulfadiazine, silver (Silvadene) B) Gentamicin sulfate C) Mafenide (Sulfamylon) D) Cerium nitrate solution
ANS: A
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? A) Hoarseness of the voice B) Urine output of 70 ml the first hour C) Moderate to severe pain D) Complaints of intense thirst
ANS: A
A patient has been diagnosed with meningitis which of the following labs would the nurse expect to see on the patients chart? A) Cloudy CSF B) Increased WBC C) Increased serum levels D) Decreased protein levels in CSF E) Increased Glucose level
ANS: A, B Rational: It will cause cloudy CSF because of the increase WBC in the CSF it will cause an increase protien levels and a decrease glucose level
A patient is admitted into the ER with a facial burn as well as a burn along the right side of the neck. Which of the following symptoms would alert the nurse to assess the patient for Carbon monoxide poisoning? (Select all that apply) A) Respiratory depression B) Nausea C) Dark sputum D) Bright red tongue E) Edema
ANS: A,B,D
A nurse suspects that that a patient has meningitis. Which of the following symptoms would lead the nurse to suspect this? (Select all that apply) A) Headache B) Photophobia C) Dizziness D) Neck righty E) Positive Brudzinski's sign
ANS: A,B,D,E
A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply: A. Acute kidney injury B. Dysrhythmia C. Iceberg effect D. Hypernatremia E. Bone fractures F. Fluid volume overload
ANS: A,BC,E
A patient with Guillain-Barré Syndrome has a feeding tube for nutrition. Before starting the scheduled feeding, it is essential the nurse? Select all that apply:* A. Assesses for bowel sounds B. Keeps the head of bed less than 30' degrees C. Checks for gastric residual D. Weighs the patient
ANS: A,C
Which of the following are the most commonly reported clinical manifestations of multiple sclerosis? (Select all that applies) A) ptosis B) Diplopia C) Aphasia D) Numbness E) Fatigued
ANS: A,D,E
As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient's urine for:* A. Hemoglobin and myoglobin B. Free iron and white blood cells C. Protein and red blood cells D. Potassium and Urea
ANS: A. Rational: Patients who've experienced a severe electrical burn or full-thickness burns are at risk for acute kidney injury. This is because the muscles can experience damage from the electrical current leading them to release myoglobin. In addition, the red blood cells will release hemoglobin. These substances will collect in the kidneys leading to acute tubular necrosis (hence leading to AKI)
A client, age 22, is admitted with bacterial meningitis.Which hospital room would be the best choice for this client? A. A private room down the hall from the nurses' station B. An isolation room three doors from the nurses' station C. A semiprivate room with a 32-year-old client who has viral meningitis D. A two-bed room with a client who previously had bacterial meningitis
ANS: B
A nurse is caring for patient with meningitis which of the following nursing interventions would be a priority for this patient? A) Pain management B) Put the patient under droplet precautions C) Monitor Serum levels D) Monitor patients daily weight
ANS: B
A patient has been diagnosed with degenerative disk disease on their C5. Which of the following symptoms would the nurse expect for this patient? A) Pain in the sacrial area B) Parasthesia in the patients hands C) Pain in the patients lower legs D) Pain in the patients lower back
ANS: B
A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. As the nurse, you know the patient needs: A. Oxygen nasal cannula 5-6 Liters B. 100% oxygen via non-rebreather mask C. Continuous Bipap D. Venturi mask 6 L oxygen
ANS: B
A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities
ANS: B
The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about a.visual problems caused by ptosis b.triggers leading to facial discomfort c.poor appetite caused by loss of taste d.weakness on the affected side of the face
ANS: B
The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest? A) Taking a hot bath at least once daily B) Resting in an air-conditioned room whenever possible C) Increasing the dose of muscle relaxants D) Avoiding naps during the day
ANS: B
You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as:* A. 1st Degree (superficial) B. 2nd Degree (partial-thickness) C. 3rd Degree (full-thickness) D. 4th Degree (deep full-thickness)
ANS: B
A patient has been brought in to the emergency department with 2nd and 3rd degree burns over 40 percent of his body. The effects of the burn on the cardiovascular system include which of the following? Select all that apply. A) Increased mean arterial pressure B) Fluid volume deficit C) ECG changes D) Hypovolemic shock E) Myocardial infarction
ANS: B,D
A patient has been prescribed Tegretol to treat their trigeminal neuralgia. Which of the following should the nurse include in this patients education? (Select all that apply) A) You may experience a slight fever B) Take this medication with meals C) this medication will help with the choria movments D) You may experience nausea E) This medication will help prevent the break down of acetylcholine
ANS: B,D
A 29 year old male patient has superficial partial thickness burns on the anterior right arm, posterior left leg, and anterior head and neck. The patient weighs 78 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours? A. 11,232 mL B. 5,616 mL C. 2,808 mL D. 16,848 mL
ANS: B. 5,616 mL
A patient has an emergency escharotomy performed on the right leg. The patient has full-thickness circumferential burns on the leg. Which finding below demonstrates the procedure was successful?* A. The patient can move the extremity. B. The right foot's capillary refill is less than 2 seconds. C. The patient reports a new sensation of extreme pain. D. The patient has a positive babinski reflex.
ANS: B. The right foot's capillary refill is less than 2 seconds.
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? A) 45% B) 18% C) 27% D) 36%
ANS: C
A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? A)The client's breathing is un-labored, and skin is clammy. B) The client's heart rate is rapid and regular. C) The client's urinary output is 0.3 to 0.5 mL/kg/hour. D) The client is alert and conscious.
ANS: C
A patient has been recently diagnosed with myasthenia gravis and ask the nurse about what this disease is doing to their body. Which of the following responses by the nurse would answer this question? A) This is a auto immue demyelinating disease B) This is an autoimmune attack on the myeline of the peripheral C) A autoimmune disease that attacks the acetylcholine receptors D) A disease which cause inflammation of the nerves and occludes blood supply
ANS: C
A patient is experiencing a flair up of MS. Which of the following medication does the nurse expect for the physician to precribe to the patient for this flair up? A) Baclofen B) Modafinil C) Methylprednisolone D) Tegretol
ANS: C
A patient with Guillain-Barr syndrome has experienced a sharp decline in vital capacity. What is the nurses most appropriate action? A) Administer bronchodilators as ordered. B) Remind the patient of the importance of deep breathing and coughing exercises. C) Prepare to assist with intubation. D) Administer supplementary oxygen by nasal cannula
ANS: C
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: A) Hypoglycemia. B) Hypocalcemia. C) Hyperkalemia. D) Hypernatremia.
ANS: C
Which medications below can help treat muscle spasms in a patient with multiple sclerosis? Select all that apply: A. Propranolol B. Isoniazid C. Baclofen D. Diazepam E. Modafinil
ANS: C,D
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? A) 9% B) 18% C) 36% D) 27%
ANS: D
During nursing report you learn that the patient you will be caring for has Guillain-Barré Syndrome. As the nurse you know that this disease tends to present with:* A. signs and symptoms that are unilateral and descending that start in the lower extremities B. signs and symptoms that are symmetrical and ascending that start in the upper extremities C. signs and symptoms that are asymmetrical and ascending that start in the lower extremities D. signs and symptoms that are symmetrical and ascending that start in the lower extremities
ANS: D
The key treatment for brain tumors is chemotherapy. True or false?
ANS: False Rational Chemo does not cross the blood brain barrier. Radiation
A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find? a) Vision changes b) Flaccid muscles c) Tremors at rest d) Absent deep tendon reflexes
ANS: a) Vision changes
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action? a. Administers a laxative b. Document the finding c. Increase the IV flow rated. d. Reposition the client on the right side
ANS: b. document the finding Rational: Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this time
Select all the TRUE statements about the pathophysiology of multiple sclerosis: A. "The dendrites on the neuron are overstimulated leading to the destruction of the axon." B. "The myelin sheath, which is made up of Schwann cells, is damaged along the axon." C. "This disease affects the insulating structure found on the neuron in the central nervous system." D. "The dopaminergic neurons in the part of the brain called substantia nigra have started to die."
The answers are B and C. In multiple sclerosis the myelin sheath (which is the insulating and protective structure made up of Schwann cells that protects the axon) is damaged. MS affects the CNS (central nervous system) and when the myelin sheath becomes damaged it leads to a decrease in nerve transmission.
A patient with Guillain-Barr syndrome has experienced a sharp decline in vital capacity. What is the nurses most appropriate action? A) Administer bronchodilators as ordered. B) Remind the patient of the importance of deep breathing and coughing exercises. C) Prepare to assist with intubation. D) Administer supplementary oxygen by nasal cannula
ans: C