MedSurg Exam VIII Brunner/ATI practice questions
A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the aura type of migraine headaches? a. Do the headaches occur multiple times a day? b. Is your headache accompanied by profuse facial sweating? c. Does your headache occur on one side of your head? d. Do you have the same manifestations each time the headache occurs?
Do you have the same manifestations each time the headache occurs?
A patient having a stroke is having difficulty forming words. What would the nurse document this finding as? a. Ataxia b. Arthralgia c. Dysphagia d. Dysarthria
Dysphagia
A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment? a. Decerebrate b. Decorticate c. Flaccid d. Rigid
Flaccid
A patient that had a stroke is experiencing memory loss and impaired learning capacity. In which lobe does the nurse determine that brain damage has most likely occurred? a. Frontal b. Occipital c. Parietal d. Temporal
Frontal
A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following actions is an appropriate action by the nurse? a. Teach the client to walk more quickly when ambulating b. Complete passive range of motion exercises daily c. Place the client on a low-protein, low-calorie diet d. Give the client extra time to perform activities
Give the client extra time to perform activities
A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the healthcare provider sutures the wound? a. Irrigates the wound to remove debris b. Gives an oral analgesic for pain c. Gives acetaminophen for headache d. Shaves the hair around the wound
Gives an oral analgesic for pain
A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? a. Hyperglycemia b. Hyponatremia c. Hypervolemia d. Oliguria
Hyponatremia
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? a. Headache b. Infection c. Aphasia d. Hypertension
Infection
A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? a. It is the only device that can be applied for stabilization of a spinal fracture b. It allows for stabilization of the cervical spine along with early ambulation c. It is less bulky and traumatizing for the patient to use d. The patient can remove it as needed
It allows for stabilization of the cervical spine along with early ambulation
A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if the same type of tumor can occur in other areas of the body. Which of the following responses should the nurse make? a. It can spread to the breasts and kidneys b. It can develop in your gastrointestinal tract c. It is limited to brain tissue d. It probably started in another area of your body and spread to your brain
It is limited to brain tissue
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? a. Phenobarbital b. Furosemide (Lasix) c. Mannitol d. Vasopressin
Mannitol
The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? a. Glycerin b. Isosorbide c. Mannitol d. Urea
Mannitol
A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor and has a respiratory rate of 12. Which of the following postoperative prescriptions should the nurse clarify with the provider? a. Dexamethasone 30 mg IV bolus BID b. Morphine sulfate 2 mg IV bolus c. Ondansetron 4 mg IV bolus PRN d. Phenytoin 100 mg IV bolus TID
Morphine sulfate 2 mg IV bolus
A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following prescriptions should the nurse clarify with the provider? a. Anticoagulant b. Plasma expanders c. H2 Antagonists d. Muscle relaxants
Muscle relaxants
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? a. Give the patient some mouthwash to gargle with b. Request an antihistamine for the postnasal drip c. Ask the patient to cough to observe the sputum color and consistency d. Notify the physician of a possible cerebrospinal fluid leak
Notify the physician of a possible cerebrospinal fluid leak
When educating a patient about the use of anticonvulsant medication, what should the nurse inform the patient is a result of long-term use of the medication in women? a. Anemia b. Osteoarthritis c. Osteoporosis d. Obesity
Osteoporosis
A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? a. Glasgow Coma Scale b. Cranial nerve function c. Oxygen saturation d. Pupillary response
Oxygen saturation
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following in an appropriate nursing intervention? a. Teach the client to scan to the right to see objects on the right side of the body b. Place the bedside table on the right side of the bed c. Orient the client to the food on the plate using the clock method d. Place the wheelchair on the client's left side
Place the bedside table on the right side of the bed
A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe? a. Keep the call light near the client b. Place the client in a room close to the nurse's station c. Encourage the client to ask for assistance d. Remind the client to walk with someone for support
Place the client in a room close to the nurse's station
A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was given a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring at this time? a. Lorazepam b. Midazolam c. Phenobarbital d. Propofol
Propofol
A nurse working in a long-term care facility is planning care for a client who has moderate Alzheimer's (mild or moderate stage). Which of the following interventions should be included in the plan of care? a. Use a gait belt for ambulation b. Thicken all liquids c. Provide protective undergarments d. Reorient the client to self and current events
Reorient the client to self and current events
A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? a. Neurogenic shock b. Paralytic ileus c. Stress ulcer d. Respiratory compromise
Respiratory compromise
A nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include? a. Rise slowly when standing b. Expect urine to become dark-colored c. Avoid foods containing tyramine d. Report any skin discoloration
Rise slowly when standing
A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods? a. Baked salmon b. Salted cashews c. Frozen strawberries d. Fresh asparagus
Salted cashews
A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? a. The vaccine is indicated to reduce the risk of respiratory infection b. The vaccine is administered in a series of four doses c. The vaccine is recommended for adolescents before starting college d. The vaccine is initially given at 2 months of age
The vaccine is recommended for adolescents before starting college
A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient? a. The patient has a new onset of diabetes b. This is significant for poor neurologic outcomes c. The patient has developed diabetes insipidus due to the location of the stroke d. The patient has liver failure
This is significant for poor neurologic outcomes
A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? a. This medication will help you with your tremors. b. This medication will help you with your bladder function c. This medication can cause your skin to bruise easily. d. This medication can cause you to experience dizziness.
This medication can cause you to experience dizziness.
A nurse is providing teaching to the partner of a client who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective? a. This medication should increase my husband's appetite b. This medication should help my husband sleep better. c. This medication should help my husband's daily functioning d. This medication should increase my husband's energy level
This medication should help my husband's daily functioning
A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? (Select all that apply). a. "I think I might be pregnant." b. "I take warfarin." c. "I take antihypertensive medication." d. "I am allergic to shrimp." e. "I ate a light breakfast this morning."
a. "I think I might be pregnant." b. "I take warfarin." d. "I am allergic to shrimp." e. "I ate a light breakfast this morning."
A nurse is beginning a physical assessment of a client who has an new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (Select all that apply). a. Areas of paresthesia b. Involuntary eye movements c. Alopecia d. Increased salivation e. Ataxia
a. Areas of paresthesia b. Involuntary eye movements e. Ataxia
A nurse is completing an assessment of a client who has increased intracranial pressure (ICP). Which of the following are expected findings? (Select all that apply). a. Disoriented to time and place b. Restlessness and irritability c. Unequal pupils d. ICP 15 mm Hg e. Headache
a. Disoriented to time and place b. Restlessness and irritability c. Unequal pupils e. Headache
A nurse is caring for a client who has Alzheimer's disease. A family member of the client asks the nurse about risk factors of the disease. Which of the following should be included in the nurse's response? (Select all that apply). a. Exposure to metal waste products b. Long-term estrogen therapy c. Sustained use of vitamin E d. Previous head injury e. History of herpes infection
a. Exposure to metal waste products d. Previous head injury e. History of herpes infection
A nurse is planning care for a patient who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply). a. Have suction equipment available for use. b. Feed the client thickened liquids c. Place food on the unaffected side of the client's mouth d. Assign an assistive personnel to feed the client slowly e. Teach the client to swallow with the neck flexed
a. Have suction equipment available for use. b. Feed the client thickened liquids c. Place food on the unaffected side of the client's mouth e. Teach the client to swallow with the neck flexed
A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply). a. Headache b. Dilated pupils c. Tachycardia d. Decorticate posturing e. Hypotension
a. Headache b. Dilated pupils d. Decorticate posturing
A nurse is assessing a client with manifestations of Parkinson's disease. Which of the following are expected findings? (Select all that apply) a. Decreased vision b. Pill-rolling tremor c. Shuffling gait d. Drooling e. Bilateral ankle edema f. Lack of facial expression
b. Pill-rolling tremor c. Shuffling gait d. Drooling f. Lack of facial expression
An emergency department nurse understands that a 110 lb recent recent stroke victim will receive at least the minimum dose of recombinant t-PA. What minimum dose will the patient receive? a. 50 mg b. 60 mg c. 85 mg d. 100 mg
50 mg
A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? a. Condom catheter b. Intermittent urinary catheterization c. Crede's method d. Indwelling urinary catheter
Condom catheter
A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation? a. Epidural hematoma b. Acute subdural hematoma c. Chronic subdural hematoma d. Grade 1 concussion
Epidural hematoma
What clinical manifestation does the nurse recognize when a patient has had a right hemispheric stroke? a. Left visual field deficit b. Aphasia c. Slow, cautious behavior d. Altered intellectual ability
Left visual field deficit
The nurse is caring for a patient with an altered level of consciousness (LOC). What is the first priority of treatment for this patient? 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
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus related to a traumatic brain injury. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? a. 50 to 100 mL/h b. 100 to 150 mL/h c. 150 to 200 mL/h d. More than 200 mL/h
More than 200 mL/h
A patient is brought to the emergency department experiencing a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? a. 12-lead electrocardiogram b. Carotid ultrasound study c. Noncontrast computed tomography d. Transcranial Doppler flow study
Noncontrast computed tomography
A nurse is caring for a client who displays manifestations of stage III Parkinson's disease. Which of the following actions should the nurse include? a. Recommend a community support group b. Integrate a daily exercise routine c. Provide a walker for ambulation d. Perform ADLs for the client
Provide a walker for ambulation
A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? A. It is safe to use microwaves that are 1200 watts or less b. You should avoid the use of CT scans with contrast c. You should place a magnet over the implantable device when you feel an aura occurring d. It is recommended that you use ultrasound diathermy for pain management
You should place a magnet over the implantable device when you feel an aura occurring
A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply). a. Avoid overwhelming fatigue b. Remove caffeinated products from the diet c. Limit looking at flashing lights d. Limit episodes of hypoventilation e. Use of aerosol hairspray is recommended
a. Avoid overwhelming fatigue b. Remove caffeinated products from the diet c. Limit looking at flashing lights
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing triad. What will the nurse recognize as the symptoms associated with Cushing triad? (Select all that apply). a. Bradycardia b. Bradypnea c. Hypertension d. Tachycardia e. Pupillary constriction
a. Bradycardia b. Bradypnea c. Hypertension
The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? (Select all that apply). a. Making nursing assessments b. Setting priorities for nursing interventions c. Anticipating needs and complications d. Initiating rehabilitation e. Ensuring that the patient regains full brain function
a. Making nursing assessments b. Setting priorities for nursing interventions c. Anticipating needs and complications d. Initiating rehabilitation
After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? (Select all that apply). a. Poor abstract reasoning b. Decreased attention span c. Short and long term memory loss d. Expressive aphasia e. Paresthesias
a. Poor abstract reasoning b. Decreased attention span c. Short and long term memory loss
A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply). a. Speak to the client at a slower rate b. Assist the client to use cards with pictures c. Speak to the client in a loud voice d. Complete sentences that the client cannot finish e. Give instructions one step at a time
a. Speak to the client at a slower rate b. Assist the client to use cards with pictures e. Give instructions one step at a time
A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply). a. Monitor for bradycardia b. Provide an emesis basin at the bedside c. Administer antipyretic medication d. Perform a skin assessment e. Keep the head of the bed flat
b. Provide an emesis basin at the bedside c. Administer antipyretic medication d. Perform a skin assessment
A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which of the following actions should the nurse include? (Select all that apply). a. Provide three large balanced meals daily b. Record diet and fluid intake c. Document weight every other week d. Offer cold fluids such as milkshakes e. Offer nutritional supplements
b. Record diet and fluid intake d. Offer cold fluids such as milkshakes e. Offer nutritional supplements
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? a. a bounding pulse b. bradycardia c. hypertension d. lethargy and stupor
lethargy and stupor
A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? a. "Do not wash your hair the morning of the procedure." b. "Try to stay awake most of the night prior to this procedure." c. "The procedure will take approximately 15 minutes." d. "You will need to lie flat for 4 hours after the procedure."
"Try to stay awake most of the night prior to this procedure."
The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient? a. 8 to 15 mm Hg b. 0 to 10 mm Hg c. 20 to 30 mmHg d. 25 to 40 mm Hg
0 to 10 mm Hg
The nurse recognizes that a patient is exhibiting symptoms associated with a TIA. After what period of time does the nurse determine these symptoms will subside? a. 1 hour b. 3 to 6 hours c. 12 hours d. 24 to 36 hours
1 hour
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? a. Up to 2 weeks b. Up to 1 week c. 1 to 3 days d. Up to 24 hours
1 to 3 days
While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak? a. 6 to 8 hours b. 18 to 36 hours c. 12 to 24 hours d. 48 to 72 hours
18 to 36 hours
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? a. 3 b. 6 c. 9 d. 12
3
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brian. What type of hematoma is this classified as? a. An epidural hematoma b. An extradural hematoma c. An intracerebral hematoma d. A subdural hematoma
An intracerebral hematoma
A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? a. Use music therapy for relaxation with the onset of a headache b. Increase physical activity when a headache is present c. Drink beverages that contain artificial sweeteners to prevent headaches d. Apply a cool cloth to the face during a headache
Apply a cool cloth to the face during a headache
A patient is admitted to the hospital with an ICP reading for 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? a. 50 mm Hg b. 60 mm Hg c. 70 mm Hg d. 80 mm Hg
70 mm Hg
A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this information from the patient? a. A thrombus formation at the site of the endarterectomy b. This is a normal occurrence after an endarterectomy and would not be a concern c. Bleeding from the endarterectomy site d. Surgical wound infection
A thrombus formation at the site of the endarterectomy
The nurse in an emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? a. Occipital skull fracture b. Temporal skull fracture c. Frontal skull fracture d. Basilar skull fracture
Basilar skull fracture
For a patient with a SCI, why is it beneficial to give oxygen to maintain a high partial pressure of oxygen (PaO2)? a. So the patient will not have respiratory arrest b. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord c. To increase cerebral perfusion pressure d. To prevent secondary brain injury
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? a. Hypophysectomy b. Application of halo traction c. Burr holes d. Insertion of Crutchfield tongs
Burr holes
A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? a. E2 + V3 + M5 = 10 b. E3 + V4 + M4 = 11 c. E4 + V5 + M6 = 15 d. E2 + V2 + M4 = 8
E3 + V4 + M4 = 11
While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have? a. Grade 1 concussion b. Grade 2 concussion c. Grade 3 concussion d. Grade 4 concussion
Grade 3 concussion
A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to assess for this finding? a. Stroke the lateral aspect of the sole of the foot b. Ask the client to blink both eyes c. Observe for facial drooping d. Have the client stand erect with eyes closed
Have the client stand erect with eyes closed
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? a. Low in fat b. Restricts protein to 10% of daily caloric intake c. High in protein and low in carbohydrate d. At least 50% carbohydrate
High in protein and low in carbohydrate
A patient has developed autonomic dysreflexia and all measure to identify a trigger have been unsuccessful. What medication can the nurse provide as prescribed by the healthcare provider to decrease blood pressure? a. Nifedipine sublingual b. Furosemide IV given rapidly c. Hydralazine hydrochloride IV given slowly d. Bumex rapid bolus IV
Hydralazine hydrochloride IV given slowly
A nurse in a clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching? a. This medication will relieve my symptoms by causing my blood vessels to dilate b. I should take this medication daily to prevent the headache from occurring c. I should expect facial flushing when I take this medication d. This medication will lower my sensitivity to food triggers
I should expect facial flushing when I take this medication
A nurse is assessing a client who reports severe headache and stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinkski's signs. Which of the following actions should the nurse perform first? a. Administer antibiotics b. Implement droplet precautions c. Initiate IV access d. Decrease bright lights
Implement droplet precautions
A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left-hemispheric stroke? a. Impulse control difficulty b. Poor judgement c. Inability to recognize familiar objects d. Loss of depth perception
Inability to recognize familiar objects
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse is observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse expect is ocurring? a. Increased ICP b. Exacerbation of uncontrolled hypertension c. Infection d. Increase in cerebral perfusion pressure
Increased ICP
A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following is the priority nursing action at this time? a. Keep neck stabilized b. Insert nasogastric tube c. Monitor pulse and blood pressure frequently d. Establish IV access and start fluid replacement
Keep neck stabilized
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? a. Keep the client in a side-lying position b. Document the duration of the seizure c. Reorient the client to the environment d. Provide client hygiene
Keep the client in a side-lying position
A patient who has had a stroke begins having complications regarding spasticity in the lower extremity. What prescribed medication does the nurse give to help alleviate this problem? a. Diphenhydramine b. Lioresal c. Heparin d. Pregabalin
Lioresal
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? a. Fluctuations in blood pressure b. Loss of cognitive function c. Ineffective cough d. Drooping eye lids
Loss of cognitive function
A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me." The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48, and observes diaphoresis on the face. What is the first action by the nurse? a. Place the patient in a sitting postion b. Call the healthcare provider c. Assess the patient for a full bladder d. Assess the patient for fecal impaction
Place the patient in a sitting postion
A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's priority? a. Prevention of further damage to the spinal cord b. Prevention of contractures of the lower extremities c. Prevention of skin breakdown of areas that lack sensation d. Prevention of postural hypotension when placing the client in a wheelchair
Prevention of further damage to the spinal cord
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? a. High-Fowler's b. Prone c. Supine d. Semi-Fowler's
Semi-Fowler's
A patient is exhibiting classic signs of a hemorrhagic stroke. What report from the patient would be an indicator of this type of stroke? a. Numbness of an arm or leg b. Double vision c. Severe headache d. Dizziness and tinnitis
Severe headache
A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54 /min. Which of the following actions should the nurse take first? a. Examine skin for irritation or pressure b. Sit the client upright in bed c. Check the urinary catheter for blockages d. Administer antihypertensive medication
Sit the client upright in bed
A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include? a. Consider taking an antacid when on this medication b. Watch for receding gums when taking the medication c. Take the medication at the same time every day d. Provide a urine sample to determine therapeutic levels of the medication
Take the medication at the same time every day
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? a. The day before the patient is discharged b. After the patient has passed the acute phase of the stroke c. After the nurse has received the discharge orders d. The day the patient has the stroke
The day the patient has the stroke
A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? a. Voice or sip-and-puff controlled electric wheelchair b. Electric or modified manual wheelchair, needs transfer assistance c. Cane d. The patient will be able to ambulate independently
The patient will be able to ambulate independently
A patient has had a large ischemic stroke and is hospitalized in the neurologic intensive care unit. What interventions will be provided to decrease intracranial pressure? (Select all that apply). a. Giving mannitol b. Maintaining the partial pressure of carbon dioxide (PaCO2) within a range of 30 to 35 mm Hg c. Giving heparin to induce anticoagulation d. Giving supplemental oxygen if the oxygen saturation is below 88% e. Elevating the head of the bed to 30 degrees
a. Giving mannitol b. Maintaining the partial pressure of carbon dioxide (PaCO2) within a range of 30 to 35 mm Hg d. Giving supplemental oxygen if the oxygen saturation is below 88%
A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should then nurse plan to take? (Select all that apply). a. Implement seizure precautions b. Perform neurologic checks four times a day c. Administer morphine for the report of neck and generalized pain d. Monitor for impaired extraocular movements e. Encourage the client to cough frequently
a. Implement seizure precautions d. Monitor for impaired extraocular movements e. Encourage the client to cough frequently
A nurse is caring for a client who has experienced a right hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (Select all that apply). a. Impulse control b. Moving the left side c. Depth perception d. Speaking e. Situational awareness
a. Impulse control b. Moving the left side c. Depth perception e. Situational awareness
A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively? (Select all that apply). a. Increased intracranial pressure b. Hemorrhagic shock c. Hydrocephalus d. Hypoglycemia e. Seizures
a. Increased intracranial pressure c. Hydrocephalus e. Seizures
A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? (Select all that apply). a. It is given to reduce the swelling of the brain. b. You will need to monitor for low blood sugar c. You might notice weight gain d. Tumor growth will be delayed e. It can cause you to retain fluids
a. It is given to reduce the swelling of the brain. c. You might notice weight gain e. It can cause you to retain fluids
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? (Select all that apply). a. Loosening constrictive clothing b. Opening the patient's jaw and inserting a mouth gag c. Positioning the patient on their side with head flexed forward d. Providing privacy e. Restraining the patient to avoid self-injury
a. Loosening constrictive clothing c. Positioning the patient on their side with head flexed forward d. Providing privacy
A nurse is assessing for the presence of Brudzinkski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (Select all that apply). a. Place the client in supine position b. Flex client's hip and knee c. Place hand behind client's neck d. Straighten the client's flexed leg at the knee
a. Place the client in supine position c. Place hand behind client's neck d. Straighten the client's flexed leg at the knee
A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "I am about to have a seizure." Which of the following actions should the nurse implement? (Select all that apply). a. Provide privacy b. Ease the client to the floor if standing c. Move furniture away from the client d. Loosen the client's clothing e. Protect the client's head with padding f. Restrain the client
a. Provide privacy b. Ease the client to the floor if standing c. Move furniture away from the client d. Loosen the client's clothing e. Protect the client's head with padding
A nurse is making a home visit to a client who has AD. The client's partner states that the client is often disoriented to time and place, is unsteady, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? (Select all that apply). a. Remove floor rugs b. Have door locks that can be easily opened c. Provide increased lighting in stairwells d. Install handrails in the bathroom e. Place the mattress on the floor
a. Remove floor rugs c. Provide increased lighting in stairwells d. Install handrails in the bathroom e. Place the mattress on the floor
The nurse is planning to provide education about prevention in the community YMCA due to the increased number of SCIs. What predominant risk factors does the nurse determine should be addressed? (Select all that apply). a. Young age b. Male gender c. Older adult d. Substance abuse e. Low-income community
a. Young age b. Male gender d. Substance abuse
A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply). a. Use the Glasglow Coma Scale when assessing the client b. Assist the client to a supine position c. Administer an opioid medication d. Encourage the patient to increase fluid intake e. Instruct the client to perform deep breathing and coughing exercises
b. Assist the client to a supine position c. Administer an opioid medication d. Encourage the patient to increase fluid intake
A nurse in a provider's office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? (Select all that apply). a. Pain is bilateral across the posterior occipital area b. Client experiences altered sleep-wake cycles c. Headache occurs approximately 1 to 8 times daily d. Client describes headache pain as dull and throbbing e. Nasal congestion and drainage occur
b. Client experiences altered sleep-wake cycles c. Headache occurs approximately 1 to 8 times daily e. Nasal congestion and drainage occur
A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply). a. Suction the endotracheal tube frequently b. Decrease the noise level in the client's room c. Elevate the client's head on two pillows d. Administer a stool softener e. Keep the client well hydrated
b. Decrease the noise level in the client's room d. Administer a stool softener
