NUR 405 Final Exam practice questions

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse? a) Slow the rate to 20 mL/hr. b) Continue the rate at 125 mL/hr. c) Slow the rate to 50 mL/hr. d) Increase the rate to 250 mL/hr.

c) Slow the rate to 50 mL/hr. The nurse should decrease the rate to 50 mL/hr to minimize cerebral edema and prevent increased intracranial pressure.

A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings? a) Nuchal rigidity b) Pupils reactive to light c) Widened pulse pressure d) Elevated temperature

c) Widened pulse pressure A widened pulse pressure is a manifestation of increased ICP. Other manifestations include bradycardia, vomiting, and decreased level of consciousness.

A demented patient states that they know you from the grocery store. What is this symptom called? a) delusion b) long-term memory loss c) confabulation d) unacceptable

c) confabulation

A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take? a) Obtain a culture of the specimen using sterile swabs. b) Allow the drainage to drip onto a sterile gauze pad. c) Suction the nose gently with a bulb syringe. d) Insert sterile packing into the nares.

b) Allow the drainage to drip onto a sterile gauze pad. The nurse should allow the drainage to drip onto a sterile gauze pad in order to assess for the presence of cerebrospinal fluid. This intervention allows for the collection of data without increasing the risk for further injury.

The client with CKD is placed on a fluid restriction of 1,500 mL/day. On the 7 a.m. to 7 p.m. shift the client drank an eight (8)-ounce cup of coffee, 4 ounces of juice, 12 ounces of tea, and 2 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client?

720 mL. Rationale: The nurse must add up how many milliliters of fluid the client drank on the 7 a.m. to 7 p.m. shift and then subtract that number from 1,500 mL to determine how much fluid the client can receive on the 7 p.m. to 7 a.m. shift. One (1) ounce is equal to 30 mL. The client drank 26 ounces (8 + 4 + 12 + 2) of fluid, or 780 mL (26 × 30) of fluid. Therefore, the client can have 720 mL (1,500 - 780) of fluid on the 7 p.m. to 7 a.m. shift.

What is the main difference between Anorexia Nervosa and bulimia nervosa? A) Binging B) Purging C) the age of the patient D) socioeconomic status of the patient

A) Binging Rationale: anorexia does not include binging

Which three interventions are important at all stages of dementia? A) Structure B) extensive assistance with ADLs C) Consistent staff D) Calm environment

A) Structure C) Consistent staff D) Calm environment Rationale: not every stage of dementia requires extensive assistance with ADLs

Which of the following would be a negative symptom of schizophrenia? A) low social engagement B) hallucinations C) delusions D) spending extravagantly

A) low social engagement Rationale: negative symptoms are something that is taken away from the normal personality

The home health nurse is caring for a 28-year-old client with a T10 SCI who says, "I can't do anything. Why am I so worthless?" Which statement by the nurse would be the most therapeutic? A. "This must be very hard for you. You're feeling worthless?" B. "You shouldn't feel worthless- you are still alive." C. "Why do you feel worthless? You still have the use of your arms." D. "If you attended a work rehab program you wouldn't feel worthless."

A. "This must be very hard for you. You're feeling worthless?" Rationale: Therapeutic communication addresses the client's feelings and attempts to allow the client to verbalize feelings; the nurse should be a therapeutic listener. TEST TAKING HINT: When the question requests a therapeutic response, the test taker should select the answer option that has "feelings" in the response.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? A. Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing. B. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson's disease. C. Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities. D. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson's disease.

A. Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing. Rationale: The nurse should not delegate feeding a client who is at risk for complications during feeding. This requires judgment that the UP is not expected to possess. TEST TAKING HINT: When reading the answer options in a question in which the nurse is delegating to an unlicensed-assistive personnel, read the stem carefully. Is the question asking what to delegate or what not to delegate? Anything requiring professional judgment should not be delegated.

The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. A. Monitor the pulse oximetry reading. B. Provide pureed foods six (6) times a day. C. Encourage coughing and deep breathing. D. Assess for autonomic dysreflexia. E. Administer intravenous corticosteroids.

A. Monitor the pulse oximetry reading. C. Encourage coughing and deep breathing. E. Administer intravenous corticosteroids. Rationale: A) Oxygen is administered initially to prevent hypoxemia, which can worsen the spinal cord injury; therefore, the nurse should determine how much oxygen is reaching the periphery. B) A C6 injury would not affect the client's ability to chew and swallow, so pureed food is not necessary. C) Breathing exercises are supervised by the nurse to increase the strength and endurance of inspiratory muscles, especially those of the diaphragm. D) Autonomic dysreflexia occurs during the rehabilitation phase, not the acute phase. E) Corticosteroids are administered to decrease inflammation, which will decrease edema, and help prevent edema from ascending up the spinal cord, causing breathing difficulties. TEST TAKING HINT: The test taker must notice where the client is receiving care, which may be instrumental in being able to rule out incorrect answer options and help in identifying the correct answer. Remember Maslow's hierarchy of needs- oxygen and breathing are priority nursing interventions.

In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock? A. No reflex activity below the waist. B. Inability to move upper extremities. C. Complaints of a pounding headache. D. Hypertension and tachycardia.

A. No reflex activity below the waist. Rationale: Neurogenic shock associated with SCI represents a sudden depression of reflex activity below the level of the injury.TI2 is just above the waist; therefore, no reflex activity below the waist would be expected. TEST TAKING HINT: If the test taker does not have any idea what the answer is, an attempt to relate the anatomical position of keywords in the question stem to words in the answer options is appropriate. In this case, T12, mentioned in the stem, is around the waist, so answer options involving the anatomy above that level (e.g., the upper extremities) can be eliminated.

The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first? A. Place the client in the Trendelenburg position. B. Turn off the dialysis machine immediately. C. Bolus the client with 500 mL of normal saline. D. Notify the healthcare provider as soon as possible.

A. Place the client in the Trendelenburg position. Rationale: The nurse should place the client's chair with the head lower than the body, which will shunt blood to the brain; this is the Trendelenburg position.

The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement? A. Teach the client to carry heavy objects with the right arm. B. Perform all laboratory blood tests on the left arm. C. Instruct the client to lie on the left arm during the night. D. Discuss the importance of not performing any hand exercises.

A. Teach the client to carry heavy objects with the right arm. Rationale: Carrying heavy objects in the left arm could cause the fistula to clot by putting undue stress on the site, so the client should carry objects with the right arm. TEST-TAKING HINT: The test taker must notice the adjectives, such as "left" and "right?" Options "2" and "3" have the nurse doing something to the arm with the fistula.

The charge nurse is making assignments. Which client should be assigned to the new graduate nurse? A. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes. B. The client diagnosed with Parkinson's disease who fell during the night and is complaining of difficulty walking. C. The client diagnosed with a cerebrovascular accident whose vitals signs are P 60, R 14, and BP 198/68. D. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.

A. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes. Rationale: Headache and photophobia are expected clinical manifestations of meningitis.The new graduate could care for this client. TEST TAKING HINT: The test taker should determine if the clinical manifestations are expected as part of the disease process. If they are, a new graduate can care for the client; if they are not expected occurrences, a more experienced nurse should care for the client.

The nurse is caring for clients on the rehabilitation unit. Which clients should the nurse assess first after receiving the change-of-shift report? A. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. B. The client with an IA SCI who is crying and very upset about being discharged home. C. The client with an L2 SCI who is complaining of a headache and feeling very hot. D. The client with a T4 SCI who is unable to move the lower extremities.

A. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. Rationale: This client has signs/symptoms of a respiratory complication and should be assessed first. TEST TAKING HINT: The nurse should assess the client who is at risk for dying or having some type of complication that requires in-tervention. Remember Maslow's hierarchy of needs, in which physiological problems are always priority and airway is the top physiological problem.

Which BMI would indicate that a patient is suffering from extreme anorexia? A) 17 B) 14 C) 19 D) 16

B) 14 Normal BMI: 18.5-25 Mild anorexia: >17 Moderate anorexia: 16-19.9 Severe anorexia: 15-15.9 Extreme anorexia: <15

A patient with anorexia presents to the emergency department for lethargy. Which intervention should you implement first? a) Discuss with them why they have not been eating b) Obtain lab work to determine if they have any electrolyte abnormalities c) Ask the parents if they have noticed a change in behavior recently

B) Obtain lab work to determine if they have any electrolyte abnormalities is correct because it is important to medically stabilize patient before thinking about mental health concerns

What nursing interventions should be implemented in early dementia treatment: A) Assist with all ADLS B) Reorient C) Educate the family that the client is terminal

B) Reorient Rationale: a patient with early dementia is still able to perform many ADLs on their own and early dementia is not yet terminal

What is the most important thing to ask a client experiencing auditory hallucinations? A) When did this start? B) What are the voices saying? C) Did you take any drugs or alcohol?

B) What are the voices saying? Rationale: assess if the hallucinations are command hallucinations and if they are telling the patient to harm themselves or others

The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? A. "You cannot just quit your dialysis. This is not an option." B. "You're angry at not being on the list, and you want to quit dialysis?" C. "I will call your nephrologist right now so you can talk to the HCP." D. "Make your funeral arrangements because you are going to die."

B. "You're angry at not being on the list, and you want to quit dialysis?" Rationale: Reflecting the client's feelings and restating them are therapeutic responses the nurse should use when addressing the client's issues. TEST-TAKING HINT: When asked to select a therapeutic response, the test taker should select an option with some type of "feeling" in the response, such as "angry" in option "2."

The rehabilitation nurse caring for the client with a Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement? A. Keep oxygen via nasal cannula on at all times. B. Administer low-dose subcutaneous anticoagulants C. Perform active lower extremity ROM exercises. D. Refer to a speech therapist for ventilator-assisted speech.

B. Administer low-dose subcutaneous anticoagulants Deep vein thrombosis (DVT) is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox) helps prevent blood from coagulating, thereby preventing DVTs. TEST TAKING HINT: The test taker should notice any adjectives such as "rehabilitation," which should clue the test taker into ruling out oxygen, which is for the acute phase. The test taker should also be very selective if choosing an answer with a definitive word such as "all" (option "1").

The client diagnosed with Parkinson's disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest X-ray. Which clinical manifestations of PD would explain these assessment data? A. Masklike facies and shuffling gait. B. Difficulty swallowing and immobility. C. Pill rolling of fingers and flat affect. D. Lack of arm swing and bradykinesia.

B. Difficulty swallowing and immobility. Rationale: Difficulty swallowing places the client at risk for aspiration. Immobility predisposes the client to pneumonia. Both clinical manifestations place the client at risk for pulmonary complications. TEST TAKING HINT: The nurse must recognize the clinical manifestations of a disease and the resulting bodily compromise. In this situation, fever and patchy infiltrates on a chest x-ray indicate a pulmonary complica-tion. Options "1,» «3," and "4? focus on motor problems and could be ruled out as too similar. Only option "2" includes dissimilar information.

The client diagnosed with septicemia expired, and the family tells the nurse the client is an organ donor. Which intervention should the nurse implement? A. Notify the organ and tissue organizations to make the retrieval. B. Explain a systemic infection prevents the client from being a donor. C. Call and notify the health-care provider of the family's request. D. Take the body to the morgue until the organ bank makes a decision.

B. Explain a systemic infection prevents the client from being a donor. Rationale: Septicemia is a systemic infection and will prevent the client from donating tissues or organs. TEST-TAKING HINT: Option "3" could be eliminated from consideration because the nurse should be able to handle this situation. Option "4" could be eliminated because the client would have to stay on life support if the organ bank were to retrieve viable organs.

The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? A. Discuss how to correctly remove the insertion pins. B. Instruct the client to report reddened or irritated skin areas. C. Inform the client that the vest liner cannot be changed. D. Encourage the client to remain in the recliner as much as possible.

B. Instruct the client to report reddened or irritated skin areas. Rationale: Reddened areas, especially under the brace, must be reported to the HCP because pressure ulcers can occur when wearing this appliance for an extended period. TEST TAKING HINT: The test taker would need basic knowledge about a halo device to answer this question easily, but some clues are in the stem. A cervical fracture is in the upper portion of the spine or neck area, and most people understand that a halo is something that surrounds the forehead or higher. So the test taker could get a mental image of a device that must span this area of the body and maintain alignment of the neck If an HCP attaches pins into the head, then the test taker could assume that they were not to be removed by the client. Redness usually indicates some sort of problem with the skin.

The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement? A. Refer the client to the American Spinal Cord Injury Association (ASIA). B. Refer the client to the state rehabilitation commission. C. Ask the social worker (SW) about applying for disability. D. Suggest that the client talk with his significant other about this concern.

B. Refer the client to the state rehabilitation commission. Rationale: The rehabilitation commission of each state will help evaluate and determine if the client can receive training or education for another occupation after injury. TEST TAKING HINT: If the question mentions a specific age for a client, the nurse should consider it when attempting to answer the question. This is a young person who needs to find gainful employment. Remember Erickson's stages of growth and development.

The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? A. The client should discuss feelings about being placed on a ventilator. B. The client may have rapid mood swings and become easily upset. C. Pill-rolling tremors will become worse when the medication is wearing off. D. The client may automatically start to repeat what another person says.

B. The client may have rapid mood swings and become easily upset. Rationale: These are psychosocial manifestations ofPD. These should be discussed in the support meeting. TEST TAKING HINT: Psychosocial problems should address the client's feelings or interactions with another person.

The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? A. The client who has hemoglobin of 9.8 g/dL and hematocrit of 30%. B. The client who does not have a palpable thrill or auscultated bruit. C. The client who is complaining of being exhausted and is sleeping. D. The client who did not take antihypertensive medication this morning.

B. The client who does not have a palpable thrill or auscultated bruit. Rationale: This client's dialysis access is compromised and he or she should be assessed first. TEST TAKING HINT: The test taker must determine which client's situation is not normal or expected for the disease process, which la his question is CKD

What is the best intervention for a client experiencing distress? A) allow them time alone B) get someone else to stay with them C) Stay with them and offer to discuss their concerns D) offer to call the chaplain

C) Stay with them and offer to discuss their concerns rationale: Safety is the priority concern. Do not leave them alone What

What is the best way to respond to a delusion? A) Pretend that it is real B) Reorient the person to reality C) Talk with person about underlying feelings D) Have them talk to their psychiatrist

C) Talk with person about underlying feelings

What is the priority for the newly admitted anorexic patient? A) feeding B) tracking weights C) assessing medical status D) group therapy

C) assessing medical status Rationale: an anorexic patient should be cleared medically before addressing the mental health portion of the anorexia

What is the priority when an assessment finds that the schizophrenic client is experiencing new EPS? A) teach relaxation techniques B) educate the family C) obtain an order to stop the medication

C) obtain an order to stop the medication Rationale: you want to put the patient on a medication that will cause them less side effects

What must the nurse complete before calling the provider with new medication side-effects noted on assessment? A) obtain a thorough history B) interview the family C) obtain current vital signs

C) obtain current vital signs Rationale: you need a baseline/current state before contacting the provider

The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? A. "All of my spouse's emotions will slow down now just like his body movements." B. "My spouse may experience hallucinations until the medication starts working." C. "I will schedule appointments late in the morning after his morning bath." D. "It is fine if we don't follow a strict medication schedule on weekends."

C. "I will schedule appointments late in the morning after his morning bath." Rationale: Scheduling appointments late in the morning gives the client a chance to complete ADLs without pressure and allows the medications time to give the best benefits. TEST TAKING HINT: The test taker could eliminate option "2" because hallucinations are never an expected part of legal medication administration.

The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement? A. Keep the client flat in bed. B. Dim the lights in the room. C. Assess for bladder distention. D. Administer a narcotic analgesic.

C. Assess for bladder distention. Rationale: This is an acute emergency caused by exaggerated autonomic responses to stimuli and only occurs after spinal shock has resolved in the client with a spinal cord injury above T6. The most common cause is a full bladder. TEST TAKING HINT: The test taker should apply the nursing process when answering questions, and assessing the client comes first, before administering any type of medication.

The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next? A. Carefully remove the driver from the car. B. Assess the client's pupils for reaction. C. Assess the client's airway. D. Attempt to wake the client up by shaking him.

C. Assess the client's airway. Rationale: The nurse must maintain a patent airway.Airway is the first step in resuscitation. TEST TAKING HINT: Remember that, in a question asking about which action should be taken first, all of the answers are interventions, but only one should be implemented first. There are very few "always" situations in the health-care profession, but in this situation, unless the client's car is on fire or under water, stabilizing the client's neck is always the priority, followed by airway.

Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? A. Teach Crede's maneuver to the client needing to void. B. Administer the tube feeding to the client who is quadriplegic. C. Assist with bowel training by placing the client on the bedside commode. D. Observe the client demonstrating self-catheterization technique.

C. Assist with bowel training by placing the client on the bedside commode. Rationale: The assistant can place the client on the bedside commode as part of bowel trainings the nurse is responsible for the training but can delegate this task. TEST TAKING HINT: Although each state has its own delegation rules, teaching, assessing, evaluating, and medication administration are nursing interventions that cannot be delegated to unlicensed assistive personnel.

The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications? A. There will be fewer side effects with this combination than with carbidopa alone. B. Dopamine D requires the presence of both of these medications to work. C. Carbidopa makes more levodopa available to the brain. D. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.

C. Carbidopa makes more levodopa available to the brain. Rationale: Carbidopa enhances the effects of levodopa by inhibiting decarboxylase in the periphery, thereby making more levodopa available to the central nervous system. Sinemet is the most effective treatment for PD. TEST TAKING HINT: The nurse must be knowledgeable of the rationale for administering a medication for a specific disease.

The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client? A. Notify the HCP if oral temperature is 102 F or greater. B. Apply ice to the access site if it starts bleeding at home. C. Keep fingernails short and try not to scratch the skin. D. Encourage the significant other to make decisions for the client.

C. Keep fingernails short and try not to scratch the skin. Rationale: Uremic frost, which results when the skin attempts to take over the function of the kidneys, causes itching, which can lead to scratching, possibly resulting in a break in the skin. TEST-TAKING HINT: The test taker must read the question carefully. A temperature of 102°F is usually not acceptable in any client. Fostering dependence in any chronic illness is not encouraged by the nurse and so the test taker could eliminate option "4."

Which is a common cognitive problem associated with Parkinson's disease? A. Emotional lability. B. Depression. C. Memory deficits. D. Paranoia.

C. Memory deficits. Rationale: Memory deficits are cognitive impairments. The client may also develop a dementia. TEST TAKING HINT: The test taker must know the definitions of common medical terms. "Cognitive" refers to mental capacity to function.

The nurse is discussing the HCP's recommendation for removal of life support with the client's family. Which information concerning brain death should the nurse teach the family? A. Positive waves on the electroencephalogram (EEG) mean the brain is dead and any further treatment is futile B. When putting cold water in the ear, if the client reacts by pulling away, this demonstrates brain death. C. Tests will be done to determine if any brain activity exists before the machines are turned off. D. Although the blood flow studies don't indicate activity, the client can still come out of the coma.

C. Tests will be done to determine if any brain activity exists before the machines are turned off. Rationale: The Uniform Determination of BrainDeath Act states brain death is determined by accepted medical standards which indicate irreversible loss of all brain function. Cerebral blood flow studies, EEG, and oculovestibular and oculoce-phalic tests may be done. TEST-TAKING HINT: If the test taker examined all answer options and did not understand options "1,» "2," and "4," then reading option "3" again would prove it to be the best choice because it simply states the machine won't be turned off until brain death has been proved.

The nurse is caring for clients on a medical-surgical floor. Which clients should be assessed first? A. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a "2" on a 1-to-10 scale. B. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes. C. The 58-year-old client diagnosed with Parkinson's disease who is crying and worried about her facial appearance. D. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.

C. The 58-year-old client diagnosed with Parkinson's disease who is crying and worried about her facial appearance. Rationale: Body image is a concern for clients diagnosed with PD. This client is the one client who is not experiencing expected sequelae of the disease. TEST TAKING HINT: At times a psychological problem can have priority. All the physical problems are expected and are not life threatening or life altering.

The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, one (1) week ago. Which complaint by the client indicates the need to notify the health-care provider? A. The client complains of flu-like symptoms. B. The client complains of being tired all the time. C. The client reports an elevation in his blood pressure. D. The client reports discomfort in his legs and back.

C. The client reports an elevation in his blood pressure. Rationale: After the initial administration of erythropoietin, a client's antihypertensive medications may need to be adjusted. Therefore, this complaint requires notification of the HCP. Erythropoietin therapy is contraindicated in clients with uncontrolled hypertension. TEST-TAKING HINT: The test taker should select the potentially life-threatening option or a complaint requiring the medication to be adjusted or discontinued. The nurse should notify the HCP if the medication is causing an adverse effect, not an expected side effect.

The nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? A. There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH. B. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis. C. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate. D. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.

C. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate. Rationale: This is the correct scientific rationale for metabolic acidosis occurring in the client with CKD. TEST-TAKING HINT: In option "1," the test taker should note "increased excretion"; CKD does not have any type of increase in excretion, so the test taker could eliminate option "1." Option "4" does not even mention the renal system and a loss of hydrochloric acid results in a metabolic alkalosis, not acidosis, so the test taker can eliminate this option.

All of the following indicate IDD except: A) Typical physical features B) Failure to meet developmentalmilestones C) Difficulty reading social cues D) IQ alone

D) IQ alone Rationale: IQ is no longer used to diagnose IDD

Delirium can be all of the following except: A) a medical emergency B) a signal of impending death C) organically caused D) entirely preventable

D) entirely preventable Rationale: there are causes that can not be prevented like TBIs

Which of the following is exclusive to delirium and not to dementia? A) Memory loss B) Slow onset C) deterioration of all cognitive domains D) rapid onset

D) rapid onset Rationale: delirium is rapid onset, dementia is slow onset

The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? A. "Do you have trouble hearing?" B. "Are you allergic to any type of dairy products?" C. "Have you eaten anything in the last eight (8) hours?" D. "Are you uncomfortable in closed spaces?"

D. "Are you uncomfortable in closed spaces?" Rationale: MRI scans are often done in a very confined space; many people who have claustrophobia must be medicated or even rescheduled for the procedure in an open MRI machine, which may be available if needed. TEST TAKING HINT: The nurse must be knowledgeable of diagnostic tests to prepare the client for the tests safely. The test taker must be realistic in determining answers--is there any test in which a hearing problem would make the diagnostic test contraindicated?

The mother of a 20-vear-old African American male client receiving dialysis asks the nurse, "My son has been on the transplant list longer than that white woman. Why did she get the kidney?" Which statement is the nurse's best response? A. "The woman was famous, and so more people will donate organs now." B. "I understand you are upset your son is ill. Would you like to talk?" C. "No one knows who gets an organ. You just have to wait and pray." D. "The tissues must match or the body will reject the kidney and it will be wasted."

D. "The tissues must match or the body will reject the kidney and it will be wasted." Rationale: There are 27 known human leukocte antigens (HLAs). HLAs have become the principal histocompatibility system used to match donors and recipients.The greater the number of matches, the less likely the client will reject the organ.Different races have different HLAs. TEST-TAKING HINT: Option "2" can be eliminated because the client asked for information. Option "1" can be eliminated because the statement supports an unethical situation.

The nurse caring for a client diagnosed with CKD writes a client problem of "noncompliance with dietary restrictions." Which intervention should be included in the plan of care? A. Teach the client the proper diet to eat while undergoing dialysis. B. Refer the client and significant other to the dietitian. C. Explain the importance of eating the proper foods. D. Determine the reason for the client not adhering to the diet.

D. Determine the reason for the client not adhering to the diet. Rationale: Noncompliance is a choice the client has a right to make, but the nurse should determine the reason for the noncompliance and then take appropriate actions based on the client's rationale. For example, if the client has financial difficulties, the nurse may suggest how the client can afford the proper foods along with medications, or the nurse may be able to refer the client to a social worker. TEST TAKING HINT: The test taker must always clarify and understand exactly what the question is asking the nurse to do. Answer options "1,» "2," and "3" have the nurse doing the talking; only option "4" is allowing the client to explain the lack of compliance.

The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is priority for the client? A. Low self-esteem. B. Knowledge deficit. C. Activity intolerance. D. Excess fluid volume.

D. Excess fluid volume. Rationale: Excess fluid volume is priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death. TEST-TAKING HINT: The test taker must read the stem of the question and understand what the question is asking. This is a priority question. This means all the options are pertinent problems for CKD, but only one is priority. Applying Maslow's bier arch one needs is one way to determine priorities: physiological problems are priority over psychosocial problems, and life-threatening conditions take first priority.

The nurse researcher is working with client diagnosed with Parkinson's disease. Which is an example of an experimental therapy? A. Stereotactic pallidotomy/ thalamotomy. B. Dopamine receptor agonist medication. C. Physical therapy for muscle strengthening. D. Fetal tissue transplantation.

D. Fetal tissue transplantation. Rationale: Fetal tissue transplantation has shown some success in PD, but it is an experimental and highly controversial procedure. TEST TAKING HINT: The test taker should not overlook the adjective "experimental." This would eliminate at least option "3," physi. cal therapy, and option "2," which refers to standard dopamine treatment, even if the test taker was not familiar with all of the procedures.

The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2°F, P 98, R 24, and BP 84/40. Which action should the nurse implement? A. Notify the health-care provider as soon as possible (ASAP). B. Calm the client down by talking therapeutically. C. Increase the IV rate by 50 mL/hour. D. Lower the head of the bed immediately.

D. Lower the head of the bed immediately. Rationale: For the first two (2) weeks after an SCI above T7, the blood pressure tends to be unstable and low; slight elevations of the head of the bed can cause profound hypo-tension; therefore, the nurse should lower the head of the bed immediately. TEST TAKING HINT: The test taker should notice that the only answer option that addresses the "bed" is the correct answer. This does not always help identify the correct answer, but it is a hint that should be used if the test taker has no idea what the correct answer is.

The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? A. Crackles in the upper lung fields and jugular vein distention. B. Muscle weakness in the upper extremities and ptosis. C. Exaggerated arm swinging and scanning speech. D. Masklike facies and a shuffling gait.

D. Masklike facies and a shuffling gait. Rationale: Masklike facies and a shuffling gait are two clinical manifestations of PD. TEST TAKING HINT: Option "3" refers to arm swing and speech, both of which are affected by PD. The test taker needs to decide if the adjectives used to describe these activities-"exaggerated" and "scanning"-are appropriate. They are not, but masklike facies and shuffling gait are.

The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? A. Request the physical therapist to consult for equipment needed. B. Request a low-fat, low-sodium diet from the dietary department. C. Provide three (3) meals per day that include nuts and whole-grain breads. D. Offer six (6) meals per day with a soft consistency.

D. Offer six (6) meals per day with a soft consistency. Rationale: The client's energy levels will not sustain eating for long periods. Offering frequent and easy-to-chew (soft) meals of small proportions is the preferred dietary plan. TEST TAKING HINT: The correct answer for a nursing problem question must address the actual problem.

The nurse is planning the care for a client diagnosed with Parkinson's disease. Which would be a therapeutic goal of treatment for the disease process? A. The client will experience periods of akinesia throughout the dav. 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.

D. The client will be able to carry out activities of daily living. Rationale: The major goal of treating PD is to maintain the ability to function. Clients diagnosed with PD experience slow, jerky movements and have difficulty performing routine daily tasks. TEST TAKING HINT: The test taker should match the goal to the problem. A "thera-peutic goal" is the key to answering this question.

The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? A. Inability to auscultate a bruit over the fistula. B. The client's abdomen is soft, is nontender, and has bowel sounds. C. The dialysate being removed from the client's abdomen is clear. D. The dialysate instilled was 1,500 mL and removed was 1,500 mL.

D. The dialysate instilled was 1,500 mL and removed was 1,500 mL. Rationale: Because the client is in ESRD, fluid must be removed from the body, so the output should be more than the amount instilled.These assessment data require intervention by the nurse. TEST-TAKING HINT: The words "warrant immediate intervention" should clue the test taker into selecting an option with abnormal or unexpected data for the client.

True or false: Clients with BED purge.

False

True or False: Parents of IDD children should be encouraged to push their children to be "normal".

False Rationale: the parents should adapt to their children's needs

True or false: IDD has an age of onset prior to age 18.

True Rationale: Diagnosis does not have to before age 18, but onset does

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? a) A change in the Glasgow Coma Scale score from 13 to 11 b) Diplopia c) A drop in heart rate from 76 to 70/min d) Ataxia

a) A change in the Glasgow Coma Scale score from 13 to 11 In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider.

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect? a) A lucid period followed by an immediate loss of consciousness b) A change in the level of consciousness that develops over 48 hr c) Neurologic deficits that increase up to 2 weeks post-injury d) Cognitive perception that decreases over several months post-injury

a) A lucid period followed by an immediate loss of consciousness The nurse should expect the client who has an epidural hematoma to have a lucid period followed by an immediate loss of consciousness, which is caused by arterial bleeding into the space between the dura and skull.

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? a) Decreased level of consciousness b) Tachypnea c) Bilateral weakness of extremities d) Hypotension

a) Decreased level of consciousness As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness, decrease. Other manifestations include severe headache, irritability, and pupils that are slow to react or are unreactive to light.

What should the nurse do if a client is agitated by their visitor? a) Explain why the client is agitated b) Encourage them to continue c) Send them away d) Tell them to stop agitating client

a) Explain why the client is agitated

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) a) Headache b) Neck pain and stiffness c) Slurred speech d) Pupillary changes e) Disorientation

a) Headache c) Slurred speech d) Pupillary changes e) Disorientation - Headache is correct. A client who has increasing ICP might manifest a headache. - Neck pain and stiffness is incorrect. Neck pain and stiffness are not manifestations of increasing ICP. - Slurred speech is correct. A client who has increasing ICP might manifest slurred speech. - Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes. - Disorientation is correct. A client who has increasing ICP might display disorientation or confusion.

A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III? a) Instruct the client to look up and down without moving his head. b) Observe the client's ability to smile and frown. c) Have the client stand with eyes his closed and touch his nose. d) Ask the client to shrug his shoulders against passive resistance.

a) Instruct the client to look up and down without moving his head. The nurse should observe the client's extraocular eye movements by instructing him to look at the cardinal fields of gaze as part of an evaluation of the function of cranial nerve III (Oculomotor).

RAISE is a program that: a) Provides early intervention after an initial psychotic break b) Helps parents to raise their children with IDD c) Encourages anorexics to gain weight d) Helps to deflate medical costs

a) Provides early intervention after an initial psychotic break

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected? a) Pushes the painful stimulus away b) Extends her body toward the painful stimulus c) Shows no reaction to the painful stimulus d) Flexes the upper and extends the lower extremities in response to the painful stimulus

a) Pushes the painful stimulus away Pushing away a painful stimulus is an expected response.

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? a) Reduce edema of the brain. b) Provide fluid hydration. c) Increase cell size in the brain. d) Expand extracellular fluid volume.

a) Reduce edema of the brain. An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream.

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? a) Test the drainage for glucose. b) Suction the nostril. c) Notify the physician. d) Ask the client to blow his nose.

a) Test the drainage for glucose. This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF, which will test positive for glucose.

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score? a) The client needs total nursing care. b) The client is alert and oriented. c) The client is in a deep coma. d) Indicates stable neurologic status

a) The client needs total nursing care. A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state and will require total nursing care.

Which of the following are EPS? (select all that apply) a) restlessness b) decreased talking c) shuffling gait d) tremors

a) restlessness c) shuffling gait d) tremors

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.) a) Confusion b) Bradycardia c) Hypotension d) Nonreactive dilated pupils e) Slurred speech

b) Bradycardia d) Nonreactive dilated pupils Bradycardia is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have tachycardia. Increased intracranial pressure can lead to nonreactive dilated pupils or constricted nonreactive pupils.

A child with Down's Syndrome in hospital. What nursing interventions should be implemented for this patient? (select all that apply) a) Keep in room b) Encourage parents to stay c) Establish routine d) Keep constant caregivers

b) Encourage parents to stay c) Establish routine d) Keep constant caregivers

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure? a) Brisk pupillary reaction to light. b) Increased sleeping c) Tachycardia d) Depressed fontanels

b) Increased sleeping Following a head injury, an infant's level of consciousness can deteriorate, show signs of excessive sleeping, and eventually go into a coma.

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse? a) PaC02 35 mm Hg b) Intracranial pressure (ICP) 18 mm Hg c) Pulse oximetry 96% d) Blood pressure 140/82 mm Hg

b) Intracranial pressure (ICP) 18 mm Hg This client's ICP level is above the expected reference range of 10 to 15 mm Hg. ICP increases with suctioning, coughing, sneezing, straining, and frequent positioning.

A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take? a) Elevate the head of bed to 45°. b) Maintain the client on absolute bed rest. c) Administer a cleansing enema. d) Place the client in a room near the nurses' station.

b) Maintain the client on absolute bed rest. The nurse should place the client on absolute bed rest in a quiet environment. Activity can elevate blood pressure and increase the risk for bleeding.

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? a) Gradual onset of several hours b) Manifestations preceded by a severe headache c) Maintains consciousness d) History of neurologic deficits lasting less than 1 hr

b) Manifestations preceded by a severe headache A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke.

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider? a) Edematous bruise on forehead b) Small drops of clear fluid in left ear c) Pupils are 4 mm and reactive to light d) Glasgow Coma Scale (GCS) score of 12

b) Small drops of clear fluid in left ear Clear fluid in the ear canal might be cerebrospinal fluid (CSF) and indicates a basilar skull fracture. CSF drainage is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents. This finding should be reported to the provider.

Which is a physical sign of purging? (Select all that apply) a) thinning hair b) lanugo c) Russell's Sign d) Deterioration of tooth enamel

c) Russell's Sign d) Deterioration of tooth enamel

A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client? a) Narrowing pulse pressure b) Drainage of clear fluid from the ears c) Alternating periods of alertness and unconsciousness d) Extensive bruising in the mastoid area

c) Alternating periods of alertness and unconsciousness Alternating periods of alertness and unconsciousness is a common manifestation of an epidural hematoma.

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first? a) Observe for cerebrospinal fluid (CSF) leaks from the evacuation site. b) Assess for an increase in temperature. c) Check the oximeter. d) Monitor for manifestations for increased intracranial pressure.

c) Check the oximeter. The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to maintain a patent airway. Checking the oximeter is the first indicator of poor oxygen exchange which can cause cerebral edema.

A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? a) Glasgow results b) Intracranial pressure readings c) Code status d) Plan of care changes for upcoming shift

c) Code status The nurse should report the client's current code stats in the background segment of SBAR.

What is separation anxiety? a) School failure b) Love of stuffed animals c) Don't want to leave attachment figure

c) Don't want to leave attachment figure

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take? a) Teach controlled coughing and deep breathing. b) Provide a brightly lit environment. c) Elevate the head of the bed 20°. d) Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day.

c) Elevate the head of the bed 20°. The nurse should elevate the head of the bed less than 25° to promote reduction of intracranial pressure.

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? a) Hypotension b) Tachycardia c) Irritability d) Tinnitus

c) Irritability The nurse should monitor the client for behavioral changes, such as confusion, restlessness, and irritability as manifestations of increased intracranial pressure.

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? a) Extension of the arms b) Pronation of the hands c) Plantar flexion of the legs d) External rotation of the lower extremities

c) Plantar flexion of the legs Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tracts.

A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take? a) Provide warming measures for the client. b) Hyperextend the client's neck. c) Flex the client's hip. d) Adjust the client's head of bed.

d) Adjust the client's head of bed. The nurse should adjust the client's head of bed to keep CPP greater than 70 mm Hg.

A nurse is implementing precautions for a client who has a cerebral aneurysm. Which following nursing interventions should the nurse implement? a) Allow bathroom privileges. d) Encourage exhaling through mouth during defecation. c) Allow natural sunlight in the room. d) Encourage visitation from family and friends.

d) Encourage exhaling through mouth during defecation. The nurse should encourage the client to exhale through her mouth when defecating to decrease strain.

A nurse is assessing a client who was involved in a motor-vehicle crash. Which of the following techniques should the nurse use to test corneal reflexes? a) Examine the eyes with a penlight. b) Instill drops of dye into the eyes. c) Visualize the red reflex of the eyes. d) Lightly touch the eyes with a wisp of cotton.

d) Lightly touch the eyes with a wisp of cotton. The nurse should lightly touch a cornea with a wisp of cotton. Absent corneal reflexes, or the loss of the ability to blink, can be caused by a head injury or stroke.

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer? a) Albumin 25% b) Dextran 70 c) Hydroxyethyl glucose d) Mannitol 25%

d) Mannitol 25% Cushing's Triad is an indication that the client is experiencing increased intracranial pressure. The nurse should administer mannitol 25%, an osmotic diuretic that promotes diuresis to treat cerebral edema.

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? a) Albumin 25% b) Dextran 70 c) Hydroxyethyl glucose d) Mannitol 25%

d) Mannitol 25% The nurse should plan to administer mannitol 25%, an osmotic diuretic that lowers intracranial pressure by promoting diuresis.

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan? a) Apply restraints. b) Administer opioids. c) Darken the room. d) Reduce stimuli.

d) Reduce stimuli. The nurse should reduce stimuli by decreasing the number of visitors, speaking calmly, and creating a quiet environment.

A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority? a) Intracranial pressure b) Serum electrolytes c) Temperature d) Respiratory status

d) Respiratory status When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respirations, noting the rate and pattern, and evaluating arterial blood gases. Following intracranial surgery, even slight hypoxia can worsen cerebral ischemia.

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion? a) Photophobia b) Nuchal rigidity c) Positive Kernig's sign d) Restlessness

d) Restlessness Clients who have meningitis can be at risk for developing increased ICP. The nurse should monitor the client's vital signs and neurological status at least every four hours. Indications of increased ICP include increased restlessness and confusion, a decreased level of consciousness, and the presence of Cushing's triad (severe hypertension, widened pulse pressure, and bradycardia).

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? a) Tachycardia b) Amnesia c) Hypotension d) Restlessness

d) Restlessness Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect? a) Loss of consciousness lasting 30 to 60 min b) Glasgow Coma Scale score of 11 c) Nuchal rigidity d) Sensitivity to light

d) Sensitivity to light The nurse should expect a client who has a mild traumatic brain injury, such as a concussion, to have sensitivity to light and noise.

What is the best response to a client experiencing delusion of persecution? a) Let's go to group and talk about it b) We need to increase your medications c) Stop thinking like that d) That must make you fearful

d) That must make you fearful

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? a) The client can follow simple motor commands. b) The client is unable to make vocal sound. c) The client is unconscious. d) The client opens his eyes when spoken to.

d) The client opens his eyes when spoken to. A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? a) Instruct the client to cough and deep breathe. b) Place the client in a supine position. c) Place a warming blanket on the client. d) Use log rolling to reposition the client.

d) Use log rolling to reposition the client. Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned.

True or False: Music can distract from auditory hallucinations.

true