Management Quiz #6

The nurse is teaching the client with tension-type headaches. Which statement indicates the client needs more teaching?

"Cold packs to the back of my neck will help my headache."

The charge nurse observes the client's nurse telling the UAP to feed an elderly client diagnosed with a CVA. Which question should the charge nurse ask the client's nurse?

"How does the client swallow the medications?"

The wife of a client diagnosed with a brain tumor tells the nurse, "I don't know how I will make it if something happens to my husband. I love him so much." Which statement is most appropriate for the nurse?

"I will call the chaplain to come and talk to you."

A client sustained a severe head injury, and his wife is concerned about what to do if he has a seizure when they go home. Which statement indicates the wife understands the most important action to take if her husband has a seizure?

"I will move all the furniture out of his way."

The client is post-op a right eye enucleation. Which statement indicates the client needs more discharge teaching?

"It will be approximately 2 weeks before I can get a prosthetic eye."

The nurse and LPN have been assigned to care for clients on a neurology unit. Which nursing task is most appropriate to assign to the LPN?

Administer the adrenocorticotropic hormone to the client with multiple sclerosis.

The nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should the nurse assign to the LPN?

Administer the client's anticoagulant subcutaneously.

The terminally ill client diagnosed with ALS has a DNR order in place and is currently complaining of "pain all over." The nurse notes the client has shallow breathing a a pulse 67, respirations 8, and BP 104/62. Which intervention should the nurse implement?

Administer the narcotic pain medication IVP.

The home health nurse is caring for a 22-year-old female client who sustained a L-5 spinal cord injury 2 months ago. The client says, "I will never be happy again. I can't walk, I can't drive, and I had to quit college." Which intervention should the nurse implement first?

Allow the client to ventilate her feelings of powerlessness.

The nurse is planning care for the client diagnosed with Parkinson's disease. Which client problem is priority?

Altered mobility.

The nurse is administering medications for clients on a neurological unit. Which medication should the nurse administer first?

An anticholinesterase medication to a client diagnosed with myasthenia gravis.

Which task is most appropriate for the clinic nurse to delegate to the UAP?

Ask the UAP to escort the client in a wheelchair to the car.

The client diagnosed with a right-sided CVA is complaining of a severe headache. Which intervention should the nurse implement first?

Assess the client's neurological status.

The nurse is caring for a client diagnosed with Alzheimer's disease. Which nursing tasks should not be delegated to the UAP? Select all that apply.

Check the client's skin under the restraints. Administer the client's antipsychotic medication.

The home health aide tells the nurse the client diagnosed with multiple sclerosis is having problems getting out of the bed to the chair, and is now having problems getting into the shower. Which intervention should the nurse implement?

Contact the agency physical therapist about the situation.

The home health nurse is admitting a female client diagnosed with myasthenia gravis. The client tells the nurse, "Even with my medication I get exhausted when I do anything." Which intervention should the nurse implement?

Contact the home health occupational therapist to discuss the client's concern.

The nurse is the first person on the scene of a MVA. The driver is in the driver's seat unconscious. Which action should the nurse implement first?

Ensure the driver has a patent airway.

The nurse on the surgical unit is working with a UAP. Which task is most appropriate for the nurse to delegate to the UAP?

Escort a client who has been discharged to the client's vehicle.

The client in a multiple car crash dies in the ED. Which priority intervention should the ED nurse implement when addressing the needs of the client's family?

Escort the family to a private room to grieve.

The client diagnosed with a CVA is confined to a wheelchair for most of the waking hours. Which intervention is priority for the nurse to implement?

Get a pressure-relieving cushion to place in the wheelchair.

The clinic nurse is making assignments for the large family practice clinic. Which task should be assigned to the staff nurse who is 4 months pregnant?

Have the staff nurse answer telephone calls from clients.

The nurse in a long-term care facility is developing the plan of care for a client diagnosed with end-stage Alzheimer's disease. Which client problem is priority for this client?

Increased risk for injury.

Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barre syndrome who is admitted to the critical care unit?

Ineffective breathing pattern.

The client diagnosed with a CVA has residual right-sided hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most appropriate for the case manager to make at this time?

Inpatient rehabilitation unit.

The client with a C-6 spinal cord injury comes to the ED complaining of a throbbing headache and has a BP of 200/120. Which intervention should the nurse implement first?

Insert an indwelling urinary catheter.

The charge nurse is making rounds and notices that the sharps container in the client's room is above the fill line. Which action should the charge nurse implement?

Instruct the UAP to change the sharps container.

The UAP is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which intervention should the nurse implement first?

Instruct the UAP to stop inserting the oral airway.

A client comes to the ED after having bleach splash in the eyes. Which intervention should the nurse implement first?

Irrigate the eyes with a sterile solution.

The 19-year-old client is in the rehab unit following a TBI. Which intervention should the nurse delegate to the UAP? Select all that apply.

Make safety rounds hourly. Assist the client with meals. Clamp and unclamp the indwelling catheter q2h.

The 24-year-old client diagnosed with a TBI is being transferred to a rehab unit. Which healthcare provider order should the nurse question?

Methylprednisolone (Solu-Medrol), a steroid, IVP q6h.

The nurse in a long-term care facility is administering medications to a group of clients. Which medication should the nurse administer first?

Neostigmine (Prostigmin) to a client diagnosed with myasthenia gravis.

The nurse enters the room, and the client is beginning to have a tonic-clonic seizure. Which action should the nurse implement first?

Note the time the client's seizure began.

The nurse caring for a client is accidentally stuck with the stylet used to start an IV infusion. The nurse flushes the skin with water and tries to get the area to bleed. Which action should the nurse implement next?

Notify the charge nurse and complete the incident report.

The nurse and UAP are caring for a minimally responsive client diagnosed with multiple sclerosis who weighs more than 400 pounds. Which action is priority when moving the client in the bed?

Obtain a lifting device made for lifting heavy clients.

The employee health nurse is caring for a male employee who reports tripping and is complaining of right knee pain. There is no visible injury, and the client has a normal neuromuscular assessment. Which intervention should the nurse implement?

Obtain a urine specimen for a drug screen.

The nurse is telling one of his graduate nurses the correct procedure for assisting the HCP with a lumbar puncture to rule out meningitis. Which interventions should the nurse discuss with the graduate nurse? Select all that apply.

Obtain an informed consent from the client or significant other. Place the client in the supine position with the foot of the bed elevated. Instruct the client to relax and breathe normally. Explain to the client what to expect during the procedure.

The nurse is caring for a client who had a C6 spinal cord injury 2 years ago and is admitted for stage IV pressure ulcers in the coccyx area. The client is complaining of a severe headache and the BP is 190/110. Which intervention should the nurse implement first?

Palpate the client's bladder.

A wife tells the clinic nurse her husband had been fine and is now confused, doesn't know where is is, and is not acting like his usual self. Which intervention should the nurse implement first?

Perform a neurological assessment.

The nurse is making rounds and as he enters the room the client is having a tonic-clonic seizure. Which priority intervention should the nurse implement?

Place the client on the side.

The client diagnosed with a right-sided CVA, or brain attack, is admitted to the rehab unit. Which interventions should be included in the nursing care plan? Select all that apply.

Position the client to prevent shoulder adduction. Refer the client to occupational therapy daily. Encourage the client to move the affected side. Perform quadriceps exercises five times a day.

The multidisciplinary team is meeting to discuss a client with right-sided weakness who has developed a stage 2 pressure ulcer over the sacral area that is not healing. Which priority intervention should the client's home health nurse recommend?

Recommend a referral to the home healthcare agency wound care nurse.

The employee health nurse is caring for an employee who fell off a ladder and is complaining of low back pain radiating down both legs. Which intervention should the nurse implement first?

Refer the client to an HCP for further evaluation.

The rehab nurse is planning the discharge of a 68-year-old client whose status post-subarachnoid hemorrhage includes residual speech and balance deficits. Which referral should the nurse initiate at this time?

Referral to a home health agency.

The client being admitted with TIA is complaining of a headache. The client is allergic to morphine, iodine, and codeine. Which HCP order should the nurse question?

Schedule for CT scan with contrast in the morning.

To which collaborative healthcare team member should the critical care nurse refer the client in the late stages of myasthenia gravis?

Speech therapist.

The nurse is at a park and observes a client fall and a stick become impaled into the right eye. Which intervention should the nurse implement first?

Stabilize the stick in the client's eye.

The clinic nurse is providing discharge instructions to an elderly client diagnosed with cataracts. Which intervention is most important for the nurse to implement?

Teach the client to increase the light in the home.

A client has been diagnosed with rule out bacterial meningitis, and a nurse is assisting the HCP with a lumbar puncture. Which intervention should the nurse implement first?

Tell the client to empty the bladder.

The home health nurse enters the home of 80-year-old female client who had a CVA 2 months ago. The client is complaining of a severe headache. Which intervention should the nurse implement first?

Tell the client to sit down, and take her BP.

The nurse and UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?

The UAP places her hand under the client's right axilla to help the client move up in bed.

The nurse and the UAP are caring for a client with right-sided CVA with hemi-paralysis. Which action by the UAP requires the nurse to intervene?

The UAP places the call light on the client's left side.

The ICU nurse and UAP are caring for a client with right-sided paralysis secondary to a CVA. Which action by the UAP requires the nurse to intervene?

The UAP places the client on the abdomen with the head to the side.

The rehabilitation nurse tells the UAP to assist the client recovering from Guillain-Barre syndrome with morning care. Which action by the UAP warrants immediate intervention?

The UAP puts the side rails up when bathing the client.

The nurse in a rehab facility is evaluating the progress of a female client who sustained a C6-C7 spinal cord injury. Which outcome indicates the client is improving?

The client can maneuver the automatic wheelchair into the hallway.

The nurse is caring for clients on a neurological ICU. Which client should be assessed first?

The client diagnosed with C6 spinal cord injury who has bradycardia, hypotension, and hyperflexia.

The nurse is caring for clients in a long-term care facility. Which client should the nurse assess first after receiving the morning report?

The client diagnosed with Parkinson's disease who began to hallucinate during the night.

The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse?

The client extends the upper and lower extremities in response to painful stimuli.

The charge nurse has received lab data for clients in the medical department. Which client would require intervention by the charge nurse?

The client receiving the anticonvulsant phenytoin (Dilantin) who has serum levels of 24mg/dL.

The community health nurse is triaging victims at the site of a disaster. Which client should the nurse categorize as black, priority 4?

The client who has full thickness burns over 60% of the body.

The clinic nurse is triaging client's telephone calls. Which client should the nurse call first?

The client whose friend has botulism who has vomiting and abdominal cramping pain.

The nurse is making shift assignments. Which client should be assigned to the most experienced nurse?

The client with ALS who is having respiratory distress.

The nurse is caring for the following clients on the neurological ICU. Which client should the nurse assess first?

The client with TBI who has a Glasgow Coma Scale score of 6.

The home health nurse is scheduling visits for the day. Which client should the nurse visit first?

The client with a C-5 spinal cord injury who reports redness and drainage at the Halo vest sites.

The nurse has just received the shift report. Which client should the nurse assess first?

The client with a C-6 spinal cord injury who has autonomic dysreflexia.

Which client should the charge nurse assess first after receiving the change-of-shift report?

The client with a C-6 spinal cord injury who is complaining of dyspnea and has a respiratory rate of 12 breaths/min.

The nurse in the neurological clinic is triaging phone calls. Which client should the nurse contact first?

The client with a tension headache who is reporting nausea and vomiting.

The critical care charge nurse is making client assignments for the shift. Which client should the charge nurse assign to the graduate nurse who just completed the orientation?

The client with amyotrophic lateral sclerosis (ALS) on a ventilator who is dying and whose family is at the bedside.

The nurse is caring for clients in the ED. Which client should the nurse assess first?

The client with an epidural hematoma.

The nurse is triaging phone calls in a neurosensory clinic. Which client should the nurse contact first?

The client with external otitis who has serosanguinous drainage and otalgia.

The nurse is caring for clients in an ophthalmology clinic. Which client warrants intervention by the nurse?

The client with primary open angle glaucoma who reports excruciating eye pain.

The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?

The elderly client who is experiencing a stroke in evolution.

The client on the rehab unit post-MVA has been prescribed 50mg of Baclofen (Lioresol) per dose orally for muscle spasms. Balofen comes in 10mg, 20mg, and 75mg tablets. How many tablets should the nurse administer and in which quantity?

The nurse should administer 2 20mg tablets and 1 10mg tablet.

The nurse is administering medications on a neurological unit. Which medication should the nurse administer first?

The osmotic diuretic to the client with a closed head injury.

The nurse is caring for a client newly diagnosed with multiple sclerosis. Which referral is appropriate at this time?

To a psychological counselor for therapy.

The charge nurse observes the new graduate nurse delegating tasks to the UAP and the UAP appears to be ignoring the graduate nurse. Which action should the charge nurse implement first?

Wait and observe how the graduate nurse handles the situation.

The ICU is very busy and the nurse is transcribing the HCP's admission orders for a client with a closed head injury. Which medication order should the nurse question?

A subcutaneous anticoagulant.

The neurologist has explained to the family of a 22-year-old client with a TBI placed on a ventilator after a MVA that the client doesn't have any brain function. Which referral is appropriate at this time?

A tissue and organ bank.