NUS 211-FINAL

A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? "Are you allergic to seafood or iodine?" "When did you last have something to eat or drink?" "How much do you weigh?" "When did you last take any medication?"

"Are you allergic to seafood or iodine?"

A female patient has presented to the emergency department (ED) with complaints of a high fever and severe headache. The patient states that acetaminophen has had no appreciable effect on either symptom. The triage nurse recognizes the need to perform a rapid assessment for possible meningitis and should ask which of the following questions: "Are you having stiffness or pain in your neck?" "Have you noticed any tremors in your hands or arms?" "Have you done any travelling in the last few weeks?" "Have you had a nosebleed since this problem started?"

"Are you having stiffness or pain in your neck?"

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? "Restrict fluid intake to 1,500 ml/day." "Avoid taking daytime naps." "Avoid hot baths and showers." "Limit your fruit and vegetable intake."

"Avoid hot baths and showers."

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? "I sense that you are happy it was not a stroke". "TIA is a warning sign. Let's talk about lowering your risks." "People who experience a TIA will develop a stroke". "TIA symptoms are short-lived and resolve within 24 hours".

"TIA is a warning sign. Let's talk about lowering your risks."

The nursing student learning on a cardiac unit asks the instructor why loss of the "atrial kick" causes a decrease in cardiac output, because the ventricles are still contracting. What is the nursing instructor's best response? "Loss of the atrial kick does not affect cardiac output; cardiac output remains the same, with or without it." "The atrial kick is only helpful if the ventricles are failing." "The atrial kick is never lost; there is always some atrial kick present." "The atrial contraction fills the ventricles and accounts for nearly one-third of the volume ejected during ventricular contraction."

"The atrial contraction fills the ventricles and accounts for nearly one-third of the volume ejected during ventricular contraction."

A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best? "Warfarin prevents atrial fibrillation from progressing to a lethal arrhythmia." "It's just a coincidence; most clients with atrial fibrillation don't receive warfarin." "Warfarin prevents clot formation in the atria of clients with atrial fibrillation." "Warfarin controls heart rate in the client with atrial fibrillation."

"Warfarin prevents clot formation in the atria of clients with atrial fibrillation."

A home care nurse is visiting a left-handed client who has an implantable cardioverter-defibrillator (ICD) implanted in the left chest. The client is planning to go rifle hunting. How should the nurse respond? "Enjoy your hunting trip." "You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." "You'll need to take an extra dose of your antiarrhythmic before you shoot." "Being that close to a rifle might make your ICD fire."

"You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site."

A client with atrial fibrillation is receiving coumadin to prevent clots from forming in the atria. The order is for Coumadin (warfarin) 2.5 mg orally daily. The medication is supplied in 1 mg tabs. How many tabs will the nurse administer to the client? Enter the correct number ONLY.

2.5

A patient with a head injury is being assessed for altered LOC and increased intracranial pressure (ICP). The patient's last ICP reading was 16 mm Hg. The nurse understands that treatment for increased ICP will be initiated at a pressure greater than: 20 mm Hg. 21 mm Hg. 19 mm Hg. 18 mm Hg.

21 mm Hg.

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome? 3 hours 6 hours 9 hours 12 hours

3 hours

The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition? 500 mL 400 mL 300 mL 600 mL

300 mL

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. 70 mm Hg 80 mm Hg 90 mm Hg 60 mm Hg

60 mm Hg

Evaluating the level of consciousness using the Glasgow Coma Scale is an essential nursing assessment for a patient who has had an intracerebral hemorrhage. Which of the following scores would indicate the need for immediate intubation? 10 8 12 15

8

A client is admitted to the emergency department reporting chest pain and shortness of breath. The nurse notes an irregular rhythm on the bedside electrocardiograph monitor. The nurse counts 9 RR intervals on the client's 6-second rhythm tracing. The nurse correctly identifies the client's heart rate as 100 bpm. 80 bpm. 70 bpm. 90 bpm.

90 bpm.

Which blood pressure (BP) reading would result in a pulse pressure indicative of shock? 100/60 mm Hg 90/70 mm Hg 130/90 mm Hg 120/90 mm Hg

90/70 mm Hg

The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate? A normal finding; the fluid will be sent for testing to determine other factors An overwhelming infection A subarachnoid hemorrhage Local trauma from the insertion of the needle

A normal finding; the fluid will be sent for testing to determine other factors

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? A rapid, bounding pulse A weak and thready pulse A slow but steady pulse A slow and imperceptible pulse

A rapid, bounding pulse

The nurse is mentoring a new graduate nurse and the two are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. Which complication(s) would the nurse identify for the new nurse? Select all that apply. Infection Penetration of the anterior tracheal wall Absence of secretions Injury to the laryngeal nerve Aspiration

Aspiration Infection Injury to the laryngeal nerve

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

Aspiration of a brain abscess

The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke? Naproxen 250 PO b.i.d. Lorazepam 1 mg SL b.i.d. PRN Calcium carbonate 1,000 mg PO b.i.d. Aspirin 81 mg PO o.d.

Aspirin 81 mg PO o.d.

The nurse is caring for a client who has just been intubated and started on mechanical ventilation in the intensive care unit. The nurse recognizes that it is possible to inadvertently intubate the right lung only. What nursing assessment and monitoring is required to determine if this complication has occurred? Select all that apply. Apply suctioning to clear the airway Monitor for both high and low pressure alarms Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Re-set the ventilator rate as needed

Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture? Comminuted Linear Basilar Simple

Basilar

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? Lumbar puncture Chest x-ray Brain CT scan or MRI Prothrombin level

Brain CT scan or MRI

A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea? Attach a pulse oximeter probe and obtain values. Listen for breath sounds over the epigastrium. Call for a chest x-ray. Observe for mist in the endotracheal tube.

Call for a chest x-ray.

A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? Administer an analgesic. Sit with the client for a few minutes. Call the physician immediately. Inform the nurse manager.

Call the physician immediately.

A patient who just suffered a hemorrhagic stroke is brought to the emergency department by ambulance. What should be the nurse's primary assessment focus? Fluid and electrolyte balance Seizure activity Urinary output Cardiac and respiratory status

Cardiac and respiratory status

A patient has had several episodes of recurrent tachydysrhythmias over the last 5 months and medication therapy has not been effective. What procedure should the nurse prepare the patient for? Insertion of a permanent pacemaker Maze procedure Insertion of an ICD Catheter ablation therapy

Catheter ablation therapy

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? Recent stress level Compliance with the prescribed medication regimen The type of anticonvulsant prescribed to manage the epileptic condition Recent weight gain and loss

Compliance with the prescribed medication regimen

The intensive care unit nurse is caring for a client who has severe brain injury with no neurological drive to breathe. This client would receive which type of mechanical ventilation? Synchronized intermittent mandatory ventilation High-frequency ventilation (HFV) Controlled mandatory ventilation (CMV) Assist control (AC)

Controlled mandatory ventilation (CMV)

Which ventilation-perfusion ratio is exhibited in a client diagnosed with a pulmonary embolus? Normal perfusion-to-ventilation ratio Silent unit Low ventilation-perfusion ratio Dead space

Dead space

What is the treatment of choice for ventricular fibrillation? Pacemaker Immediate bystander CPR Atropine Implanted defibrillator

Immediate bystander CPR

A patient is recovering from a motor vehicle accident, which has necessitated mechanical ventilation in the intensive care unit (ICU). The ICU nurse is aware that multiple nursing diagnoses are associated with mechanical ventilation. Which of the following nursing diagnoses is a consequence of mechanical ventilation? Risk for Imbalanced Body Temperature Impaired Verbal Communication Moral Distress Acute Confusion

Impaired Verbal Communication

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate? Depress the central nervous system Dilate the bronchial tree Increase the force of myocardial contraction Slow the heart rate

Increase the force of myocardial contraction

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

Mannitol

Which disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells? Huntington disease Creutzfeldt-Jakob disease Multiple sclerosis Parkinson disease

Parkinson disease

A 55-year-old female client presents at the walk-in clinic complaining of feeling like a mask is on her face. While doing the initial assessment, the nurse notes the demonstration of a pill-rolling movement in the right hand and a stooped posture. Physical examination shows bradykinesia and a shuffling gait. What would the nurse suspect is the causative factor for these symptoms? Multiple sclerosis Parkinson's disease Huntington's disease Myasthenia gravis

Parkinson's disease

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? Performing a lumbar puncture Placing him on mechanical ventilation Giving him a barbiturate Elevating the head of his bed

Performing a lumbar puncture

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? Help the client complete his or her sentences as needed. Speak in a loud and deliberate voice to the client. Provide a board of commonly used needs and phrases. Have the client speak to loved ones on the phone daily.

Provide a board of commonly used needs and phrases.

Family members of a client with traumatic brain injury are extremely distressed about their loved one. How can the nurse best assist the family to cope during this acute phase? Wait for the family members to approach with questions. Provide factual information and emotional support. Reassure them that progress will be made, but it takes time. Allow family members distance and space to deal with the changes to the client.

Provide factual information and emotional support.

Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? QT interval PR interval P wave QRS complex

QRS complex

A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client? Reduce hypertension and high blood cholesterol Increase body weight moderately Increase hydration and the intake of fluids Increase intake of proteins and carbohydrates

Reduce hypertension and high blood cholesterol

The staff educator is presenting a class on cardiac dysrhythmias. How would the educator describe the characteristic pattern of the atrial waves in atrial flutter? Square Sinusoidal Triangular Sawtooth

Sawtooth

The nurse anticipates that an immunosuppressed client is at greatest risk for which type of shock? Septic Neurogenic Cardiogenic Anaphylactic

Septic

Which type of shock is caused by an infection? Cardiogenic Anaphylactic Septic Hypovolemic

Septic

Which ventilation-perfusion ratio is exhibited in a client diagnosed with ARDS? Normal perfusion-to-ventilation ratio Silent unit Low ventilation-perfusion ratio Dead space

Silent unit

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis? A decreased body temperature will signal the need to cover the client. An elevated temperature indicates cerebellum malfunction. An elevated body temperature indicates infection. The stroke may have impacted the body's thermoregulation centers.

The stroke may have impacted the body's thermoregulation centers.

When no atrial impulse is conducted through the AV node into the ventricles, the client is said to be experiencing which type of AV block? First degree Third degree Second degree, type I Second degree, type II

Third degree

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following? Clopidogrel Extended release dipyridamole Tissue plasminogen activator (tPA) Atorvastatin

Tissue plasminogen activator (tPA)

Which of the following is the chief cause of intracerebral hemorrhage (ICH)? Hypercholesterolemia Migraine headaches Uncontrolled hypertension Diabetes

Uncontrolled hypertension

The client is admitted into the emergency department with diaphoresis, pale, clammy skin, and BP of 90/70. Which intervention would the nurse implement first? a. Start an IV with an 18 gauge catheter b. Administer dopamine intravenous infusion. c. Obtain arterial blood gasses d. Insert an indwelling urinary catheter.

a. Start an IV with an 18 gauge catheter

A nurse recognizes that which of the following is an indication of organ dysfunction as a result of shock? a. elevated liver function tests b. urine output of 30ml/hr c. SpO2 of 91% d. decreased lactate levels

a. elevated liver function tests

The nurse is caring for a ventilated client after coronary artery bypass graft surgery. What are the criterions for extubation for the client? Select all that apply. adequate cough and gag reflexes acceptable arterial blood gas values labile vital signs breathing without assistance of the ventilator inability to speak

adequate cough and gag reflexes acceptable arterial blood gas values breathing without assistance of the ventilator

A client was admitted to the hospital unit with an elevated leukocyte count and a fever accompanied by warm, flushed skin. These symptoms suggest that the client has: an overwhelming bacterial infection. had a severe allergic reaction to a bee sting. had an overdose of opioids. lost blood from frequently using NSAIDs.

an overwhelming bacterial infection.

Which are possible long-term complications of spinal cord injury? Select all that apply. respiratory infection autonomic dysreflexia areflexia respiratory arrest

autonomic dysreflexia respiratory infection

A patient with a spinal cord injury from 2 years ago is experiencing wheezing, respiratory distress and complaints of throat swelling after eating a new dessert. On arrival to the ED the patient is hypotensive. The nurse suspects the patient is experiencing which type of shock?a. Neurogenic shock b. Anaphylactic shock c. Septic shock d. Hypovolemic shock

b. Anaphylactic shock

The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first? a. Schedule a STAT Magnetic Resonance Imaging of the brain b. Call a code STROKE c. Notify the health care provider. d. Elevate the left arm

b. Call a code STROKE

A client is at risk for shock. What is the earliest indication that the client is experiencing shock? a. anuria b. narrowed pulse pressure c. hypotension d. decreased level of consciousness

b. narrowed pulse pressure

The nurse is teaching a patient with a transient ischemic attack about aspirin therapy. Which statement by the patient indicates understanding of the reason for his aspirin therapy? a. I must take the aspirin regularly to prevent the headache that many people have with this disorder." b. "If I take aspirin, I am less likely to develop bleeding in my brain." c. "The aspirin will help prevent me from having a stroke. "d. "Taking aspirin regularly will reduce my chances of having a heart attack."

c. "The aspirin will help prevent me from having a stroke.

The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? a. Vital signs T 100.4, P 104, R 26, and BP 102/60 b. A white blood cell count of 18,000/mm3. c. A urinary output of 40 mL in the last four hours. d. The client complains of being thirsty.

c. A urinary output of 40 mL in the last four hours.

A patient with a stroke stares at the nurse but does not attempt to respond to the nurse's questions. The patient is able to follow directions. The nurse understands the patient's symptoms are consistent with: a. Receptive aphasia b. Global aphasiac. c. Expressive aphasia d. Dysarthria

c. Expressive aphasia

A patient arrives at the ED with stroke symptoms. Tissue plasminogen activator is being considered. The nurse should first: a. Ask what medications the patient is taking b. Complete a history and health assessment c. Identify the time of onset of the stroked. d. Determine if any surgical procedures are scheduled

c. Identify the time of onset of the stroked.

The nurse is teaching a family of a patient with dysphagia about decreasing the risk of aspiration. Which of the following strategies is not appropriate? a. Maintain an upright position. b. Restrict the diet to liquids until swallowing improves. c. Introduce foods on unaffected side of mouth d. Keep distractions to a minimum.

c. Introduce foods on unaffected side of mouth

A patient is diagnosed with a right hemispheric stroke. The nurse should expect the patient to have which symptom? a. Right hemiparesis b. Expressive aphasia c. Poor impulse control d. Marked anxiety when learning new tasks

c. Poor impulse control

A patient is admitted with a urinary tract infection and septic shock. Which of the following lab results supports a diagnosis of septic shock? a. Brain natriuretic peptide (BNP) of 80 b. White blood cell count of 9.0 c. Hemoglobin of 12.5 d. Elevated lactate level

d. Elevated lactate level

A patient comes in to the urgent care center complaining of shortness of breath and dizziness after being stung by a bee. The patient loses consciousness in the waiting room. The nurse anticipates that which medication will be considered first? a. Diphenhydramine IV b. Phenytoin c. Epinephrine IV d. Epinephrine IM

d. Epinephrine IM

In evaluating the effectiveness of therapy for a hypotensive patient in sepsis who is receiving a fluid bolus of NSS, the nurse determines which of the following is a determination of improvement? a. Urine output of 20mL/hr for the past 2 hours b. CVP of 4mmHg c. SPO2 of 92% d. MAP of 69mmHg

d. MAP of 69mmHg

The client has been diagnosed with a stroke. The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?a. Obtain a rubber mat to place under the dinner plate. b. Purchase a long-handled bath sponge for showering. c. Purchase clothes with Velcro closure devices. d. Obtain a raised toilet seat for the client's bathroom.

d. Obtain a raised toilet seat for the client's bathroom.

A critical care nurse is providing care to a client being mechanically ventilated. The low pressure alarm sounds. The nurse would assess for which situation? biting of the endotracheal tube kinking of the tubing evidence of bronchospasm disconnection from the ventilator

disconnection from the ventilator

Which of the following is true of positive-pressure ventilators? expiration occurs passively a vacuum pulls air into the lungs alveoli constrict to conserve air in the bronchi a preset pressure forces expiration

expiration occurs passively

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

place the client on his side, remove dangerous objects, and protect his head.

A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to: reduce the chance of blood clot formation. enhance the immune response. prevent intracranial bleeding. control headache pain.

reduce the chance of blood clot formation.

A client who has been brought to the ED is unresponsive, and has an elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The high school where the client is employed has had a significant increase in cases of staphylococcal and streptococcal infections among student athletes. The client's labs show an elevated white blood cell count; cultures are forthcoming. What does the nurse suspect may be the cause of the client's present condition? cardiogenic shock anaphylactic shock septic shock neurogenic shock

septic shock

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: nutritional protocol will be effective after the client sedation therapy is tapered. she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. payment status will change if the client isn't sedated. to continue IV administration of other scheduled medications.

she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

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

shivering in hypothermia can increase ICP.

A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What type of dysrhythmia would the cardiologist likely diagnose? sinus tachycardia supraventricular tachycardia supraventricular bradycardia sinus bradycardia

sinus tachycardia

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? Atrial fibrillation Supraventricular tachycardia Bundle branch block Ventricular tachycardia

Atrial fibrillation

While caring for a patient with an endotracheal tube the nurse recognizes that suctioning is required: When adventitious breath sounds are auscultated To prevent the patient from coughing To stimulate the cough reflex Every 2 hours

When adventitious breath sounds are auscultated

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?" Given the client's condition, which statement is most correct? "The client is in shock because the heart is unable to circulate the body fluids." "The client is in shock because the blood volume has decreased in the system." "The client is in shock because all peripheral blood vessels have massively dilated." "The client is in shock because your loved one is not responding and brain dead."

"The client is in shock because the blood volume has decreased in the system."

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? "The client is unaware of his left side. You should approach him on the right side." "The client is unaware of his left side. You need to encourage him to interact from this side." "This condition is temporary." "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side."

"The client is unaware of his left side. You should approach him on the right side."

While teaching a CPR class, a student in the class asks what the difference is between cardioversion and defibrillation. What would be the nurse's best response? "Cardioversion is always attempted before defibrillation because it is not as dangerous." "Cardioversion is done on a beating heart; defibrillation is not." "The difference is the timing of the delivery of the electric current." "Defibrillation is synchronized with the electrical activity of the heart; cardioversion is not."

"The difference is the timing of the delivery of the electric current."

An older adult man has been diagnosed with Parkinson's disease and has begun treatment with levodopa and carbidopa. When providing health education about his new medication regimen, what should the nurse teach the man? "If you're consistent with taking your medication, you might not experience symptoms for several more years." "This medication helps significantly but the benefits tend to decrease over time." "The beneficial effects of this medication usually increase over time, so you may not get maximum relief for a few years." "This medication can cure Parkinson's disease, but this is not necessarily the case for everyone."

"This medication helps significantly but the benefits tend to decrease over time."

A client with quadriplegia is in spinal shock. What finding should the nurse expect? Spasticity of all four extremities Absence of reflexes along with flaccid extremities Hyperreflexia along with spastic extremities Positive Babinski's reflex along with spastic extremities

Absence of reflexes along with flaccid extremities

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? Absolute bed rest in a quiet, non stimulating environment Supine positioning Early initiation of physical therapy Passive range-of-motion exercises to prevent contractures

Absolute bed rest in a quiet, non stimulating environment

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

Administer stool softeners.

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? Bradycardia Slurred speech Alteration in level of consciousness (LOC) Decreased heart rate

Alteration in level of consciousness (LOC)

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? Tonic-clonic seizures Alteration in level of consciousness (LOC) Generalized pain Shortness of breath

Alteration in level of consciousness (LOC)

The nurse is caring for a male client who is scheduled for a neurologic examination that uses a radiopaque dye. Before the test, the nurse assesses the allergy history of the client and find the client is allergic to seafood. What does the nurse relate the allergy to seafood as? An allergy to antihistamines An allergy to morphine An allergy to radiation exposure An allergy to iodine

An allergy to iodine

A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is A young female adolescent who developed shock from tampon use during menses An older adult man with end-stage renal disease and an infected dialysis access site A middle-aged woman with metastatic breast cancer and a BMI of 26 An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection

An older adult man with end-stage renal disease and an infected dialysis access site

Which assessment data does the nurse recognize as the most sensitive indicator of increased ICP? • A. Pupillary • B. Respiratory • C. Level of consciousness • D. Cranial nerves

Answer C : Level of Consciousness

A patient with a history of seizures experiences lip smacking and daydreams during a seizure with no loss of consciousness. The nurse recognizes these clinical manifestations as associated with which type of seizure? • A. Absence seizure • B. Complex partial seizure • C. Atonic seizure • D. Myoclonic seizure

Answer C: Absence Seizures

The nurse correlates which clinical manifestation to a secondary headache?• A. Sudden severe onset• B. Tense neck muscles• C. Nausea• D. Tingling scalp sensation

Answer: A Sudden severe onset

A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension? Avoid binders around the abdominal area. Practice with the client raising the head in one smooth, quick motion. Apply anti-embolic stockings prior to elevation of the head. Avoid vasopressor medication for 2 hours prior to the client sitting up.

Apply anti-embolic stockings prior to elevation of the head.

The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? Serum thyroid level findings Red blood cells (RBCs) and hemoglobin count findings Arterial blood gas (ABG) findings White blood cell count findings

Arterial blood gas (ABG) findings

A patient who suffered a T6 lesion during a spinal cord injury (SCI) 10 days ago is progressing with treatment and rehabilitation following the immediate treatment of his injury. When preparing to help the physical therapist mobilize the patient for the first time since the injury, the nurse should prioritize which of the following assessments? Assessing the patient's blood pressure Assessing the patient's respiratory rate Monitoring the patient's pain level Monitoring the patient's cognition

Assessing the patient's blood pressure

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

Assist the client to the floor, in a side-lying position, and protect him with linens.

A nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The client's blood pressure is 80/50 mm Hg and the client reports dizziness. Which medication does the nurse anticipate administering to treat bradycardia? Atropine Dobutamine Amiodarone Lidocaine

Atropine

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? Orthostatic hypotension Thrombophlebitis Spinal shock Autonomic dysreflexia

Autonomic dysreflexia

A nurse is caring for a client who has had an automatic cardiac defibrillator implanted. What instructions should the nurse provide to the client? Avoid driving for at least 3 months. Avoid devices with a magnetic field. Use digital cellular telephones. Avoid using microwave ovens.

Avoid devices with a magnetic field.

The nurse cares for a client following the insertion of a permanent pacemaker. What discharge instruction(s) should the nurse review with the client? Select all that apply. Refrain from walking through antitheft devices Avoid the usage of microwave ovens and electronic tools Wear a medical alert, noting the presence of a pacemaker Check pulse daily, reporting sudden slowing or increase Avoid handheld screening devices in airports

Avoid handheld screening devices in airports Check pulse daily, reporting sudden slowing or increase Wear a medical alert, noting the presence of a pacemaker

Which postimplantation instruction must a nurse provide to a client with a permanent pacemaker? Avoid sources of electrical interference Keep moving the arm on the side where the pacemaker is inserted Delay activities such as swimming and bowling for at least 3 weeks Keep the arm on the side of the pacemaker higher than the head

Avoid sources of electrical interference

The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock? Increased capillary perfusion Increased hunger Decreased urinary output Decreased thirst

Decreased urinary output

The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern? Blood pressure 128/86 mm Hg Mild neck edema Neck pain rated 3 of 10 (on a 0 to 10 pain scale) Difficulty swallowing

Difficulty swallowing

While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand? Guaifenesin (Robitussin) Loperamide (Imodium) Diphenhydramine (Benadryl) Pseudoephedrine (Sudafed)

Diphenhydramine (Benadryl)

Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. The nurse knows elective cardioversion prevents what? Disrupting the heart during the critical period of atrial repolarization. Disrupting the heart during the critical period of ventricular repolarization. Disrupting the heart during the critical period of ventricular depolarization. Disrupting the heart during the critical period of atrial depolarization.

Disrupting the heart during the critical period of ventricular repolarization.

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for? Pruritus Dyskinesia Diarrhea Lactose intolerance

Dyskinesia

A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests? Transesophageal echocardiogram (TEE), troponin levels, and a complete blood count EEG, blood cultures, and neuroimaging studies X-ray of the brain, bone marrow aspiration, and EEG Electrocardiography, TEE, prothrombin time (PT), and International Normalized Ratio (INR)

EEG, blood cultures, and neuroimaging studies

Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply. Breathing Writing Ambulating Eating Transferring to a wheelchair

Eating Breathing Transferring to a wheelchair Writing

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance? Cover the client with a blanket. Shake the client to arouse. Place a cool compress on head. Elevate the legs higher than the heart.

Elevate the legs higher than the heart.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? Turned onto the operative side Flat Elevated no more than 10 degrees Elevated 30 degrees

Elevated 30 degrees

The nurse is caring for a client with head trauma. Which assessment finding(s) would indicate an increasing intracranial pressure (ICP) in this client? Select all that apply. Elevated systolic blood pressure Wide pulse pressure Glasgow Coma Scale of 15 Generalized pain Stiff neck Brisk pupil response

Elevated systolic blood pressure Wide pulse pressure

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? Position changes every 15 minutes while awake Elevation of the head of the bed Extension of the neck Head turned slightly to the right side

Elevation of the head of the bed

A client presents to the emergency department after being stung by a bee, complaining of difficulty breathing. What vasoconstrictive medication should be given at this time? Dexamethasone Diphenhydramine Prednisone Epinephrine

Epinephrine

A client presents to the emergency department with her spouse. The client appears to be in respiratory distress. The spouse states, "I think she ate a dessert made with peanuts; she's allergic to peanuts." The nurse should administer which agent first? Albuterol nebulizer Epinephrine intramuscularly IV infusion of normal saline Diphenhydramine IV

Epinephrine intramuscularly

An 11-year-old client has been brought to the emergency department by their parent, who reports that the client may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. Which interventions should the nurse prioritize? Establishing central venous access and beginning fluid resuscitation Performing a comprehensive assessment and initiating rapid fluid replacement Establishing peripheral intravenous (IV) access and administering IV epinephrine Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)

Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)

The client with a brain tumor may be at increased risk for aspiration. What does the nurse determine is the most important nursing intervention? Assistance with self-care Evaluation of gag reflex and ability to swallow Monitoring vital signs Frequent reorientation

Evaluation of gag reflex and ability to swallow

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? Keep the television on while she speaks. Talk in a louder than normal voice. Face the client and establish eye contact. Use one long sentence to say everything that needs to be said.

Face the client and establish eye contact.

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? Periorbital edema Facial droop Projectile vomiting Dysrhythmias

Facial droop

A client receives a pacemaker to treat a recurring arrhythmia. When monitoring the cardiac rhythm strip, the nurse observes extra pacemaker spikes that don't precede a beat. Which condition should the nurse suspect? Failure to sense Asystole Failure to capture Failure to pace

Failure to capture

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? Burning sensation on urination Lower back pain Fever and change in urine clarity Frequency of urination

Fever and change in urine clarity

An older adult patient has experienced a severe exacerbation of chronic obstructive pulmonary disease and requires mechanical ventilation. Which of the following settings will be specified by the primary care provider? Select all that apply. Tidal volume Respiratory rate CO2 saturation level Positive end expiratory pressure Fraction of inspired oxygen

Fraction of inspired oxygen Respiratory rate Tidal volume Positive end expiratory pressure

From which direction should a nurse approach a client who is blind in the right eye? From the right side of the client From directly in front of the client From directly behind the client From the left side of the client

From the left side of the client

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

Generalized

The victim of a motor vehicle accident has been admitted with massive trauma, including traumatic brain injury. Emergency treatment of increased intracranial pressure (ICP) has failed to resolve the problem, and monitoring reveals the ominous presence of Cushing's triad. What assessment findings would be consistent with this clinical phenomenon? HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute PaO2 70 mm Hg; RR 12 breaths per minute; HR 116 beats per minute pH 7.2; PaO2 72 mm Hg; HCO3 20 mEq/L Temperature 104°F (40°C); RR 33 breaths per minute; HR 111 beats per minute

HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute

A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices? Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids Hanging tape on the bedside table when changing a wet-to-dry sterile dressing Rubbing the hands together with antiseptic solution until dry when exiting the client's room

Hanging tape on the bedside table when changing a wet-to-dry sterile dressing

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? Allow optimum physical activity before meals to expedite digestion Help the client sit upright when eating and feed slowly Instruct the client to lie on the bed when eating Offer liquids frequently, in large quantities

Help the client sit upright when eating and feed slowly

A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects? High blood pressure Respiratory distress Migraine attacks Hemorrhage

Hemorrhage

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? Autoregulation Herniation Monro-Kellie hypothesis Cushing response

Herniation

Which terms refers to blindness in the right or left half of the visual field in both eyes? Diplopia Homonymous hemianopsia Nystagmus Scotoma

Homonymous hemianopsia

A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified? Advanced age Hypertension African heritage Male gender

Hypertension

The nurse enters the client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client? Electric cardioversion Immediate defibrillation Chemical cardioversion IV lidocaine

Immediate defibrillation

The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client? Hypervolemia Hypovolemia Increased intracranial pressure Decreased intracranial pressure

Increased intracranial pressure

A client had a tracheostomy two hours ago. The nurse assesses the client and finds the client's breathing is shallow, with a respiratory rate of 30. The nurse notes increased mucus production around the tracheostomy and on the dressing. What are the priority nursing concern(s)? Select all that apply. Infection risk Impaired gas exchange Knowledge deficiency Altered body image perception Ineffective airway clearance

Ineffective airway clearance Impaired gas exchange

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? Impaired physical mobility Ineffective breathing pattern Disturbed sensory perception (tactile) Dressing or grooming self-care deficit

Ineffective breathing pattern

A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene? The nurse should do nothing because she is responsible only for inpatient care. Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge. Suggest that the family members speak with the physician about their concerns. Contact the appropriate agencies so that they can provide care after discharge.

Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge.

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? A large volume enema Digital stimulation Insertion of a nasogastric tube Bowel surgery

Insertion of a nasogastric tube

A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury? Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. Encourage the family to reprimand the client if he doesn't ask for help with transfers and mobility. Ask a physician to order a vest and wrist restraints. Encourage the client to do as much as possible without assistance, and to use the call light only in emergencies.

Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed.

Which of the following are disease-modifying agents used in the treatment of multiple sclerosis (MS)? Select all that apply. Interferon beta-1a (Avonex) Tizanidine (Zanaflex) Glatiramer acetate (Copaxone) Interferon beta-1b (Betaseron) Interferon beta-1a (Rebif)

Interferon beta-1a (Rebif) Interferon beta-1b (Betaseron) Interferon beta-1a (Avonex) Glatiramer acetate (Copaxone)

The treatment of choice for a spinal cord-injured patient with impaired bladder emptying would include which of the following? Indwelling catheterization Intermittent self-catheterization Condom catheterization No catheterization is necessary

Intermittent self-catheterization

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Schedule the client for pulmonary surgery Increase oxygen administration Intubate the client and control breathing with mechanical ventilation Administer a large dose of furosemide (Lasix) IVP stat

Intubate the client and control breathing with mechanical ventilation

The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock? It causes respiratory distress syndrome. It begins when peripheral blood flow is inadequate. It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. It is a component of any trauma.

It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.

A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: Jugular venous distention Positive increase in the fluid balance ratio Vesicular breath sounds Decreased pulse rate to 110 beats/minute

Jugular venous distention

A patient is being cared for after suffering a traumatic brain injury in a motorcycle accident. Since the patient has regained consciousness, the nurse has been prioritizing assessments related to the possibility of increased intracranial pressure (ICP). Assessment for early signs of increased ICP should focus most closely on which of the following parameters? Level of consciousness (LOC) Vital signs Pain level Muscle tone

Level of consciousness (LOC)

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess Bowel sounds Mental status Skin perfusion Lung sounds

Lung sounds

A nurse should obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia? Calcium and magnesium Potassium and sodium Magnesium and potassium Potassium and calcium

Magnesium and potassium

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? Prevent complications of immobility. Relieve anxiety and pain. Maintain and improve cerebral tissue perfusion. Relieve sensory deprivation.

Maintain and improve cerebral tissue perfusion.

A new ancillary staff member is assisting the nurse with a client diagnosed with Parkinson's disease. The client needs assistance with eating but doesn't require thickened liquids to aid swallowing. Which instruction should the nurse give the ancillary staff member about eating assistance? Make sure the client is sitting with the head of bed elevated to 90 degrees. Clients with Parkinson's disease shouldn't have liquids; remove them from the dinner tray before serving food to the client. There are no special precautions for the client with Parkinson's disease. Assist the client into a comfortable position and stay alert for coughing, which signifies aspiration.

Make sure the client is sitting with the head of bed elevated to 90 degrees.

The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death? Brain death Multiple organ failure Endotoxins in the system Limited gas exchange

Multiple organ failure

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord? Huntington disease Parkinson disease Creutzfeldt-Jakob disease Multiple sclerosis

Multiple sclerosis

Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere? Expressive aphasia Neglect of the left side Inability to move the right arm Neglect of the right side

Neglect of the left side

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? Computed tomography (CT) scan Radiography Neurologic examination Myelography

Neurologic examination

The emergency department nurse is caring for a patient who has gone into cardiac arrest. The nurse is performing external defibrillation. Which of the following is a vital step in the procedure? Continue to ventilate the patient via endotracheal tube during the procedure. Gel pads are placed anteriorly, over the apex, and posteriorly for better conduction. No one is to be touching the patient at the time shock is delivered. Second shock cannot be administered for 1 minute to allow recharging.

No one is to be touching the patient at the time shock is delivered.

Which is the initial diagnostic test for a stroke? Carotid Doppler Noncontrast computed tomography Transcranial Doppler studies Electrocardiography SUBMIT ANSWER

Noncontrast computed tomography

The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? Acetaminophen may be administered for aches. A light meal may be eaten if desired. Observe for any signs of behavioral changes. Follow up with regular physician is encouraged.

Observe for any signs of behavioral changes

There is a high risk for ineffective coping in a client with a recent spinal cord injury. Which nursing interventions will assist the client with this process? Select all that apply. Offer encouragement as the client makes progress. Reassure the client by stating, "Everything is going to be all right." Assist the client in accepting the severity of deficits. Involve the client actively in self care.

Offer encouragement as the client makes progress. Involve the client actively in self care.

A patient receiving plasma develops transfusion-related acute lung injury (TRALI) 4 hours after the transfusion. What type of aggressive therapy does the nurse anticipate the patient will receive to prevent death from the injury? (Select all that apply.) Fluid support Intubation and mechanical ventilation Oxygen Serial chest x-rays Intra-aortic balloon pump

Oxygen Fluid support Intubation and mechanical ventilation

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? QRS complex PR interval P wave T wave

P wave

The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client? Allowing ample time to eat Assisting the client with meals Placing food on the affected side of the mouth Testing the gag reflex before offering food or fluids

Placing food on the affected side of the mouth

A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. Which intervention may improve oxygenation and provide comfort for the client? Administer small doses of pancuronium Position the client in the prone position Force fluids for the next 24 hours Assist the client into a chair

Position the client in the prone position

A critical care nurse is aware of the high incidence and prevalence of ventilator-associated pneumonia (VAP) in high-acuity settings. In order to reduce patients' risks of developing VAP, what intervention should the nurse prioritize? Auscultate the patient's lungs at least every 6 hours. Maintain the patient in a supine position whenever possible. Provide frequent, thorough mouth care. Administer prophylactic intravenous antibiotics as ordered.

Provide frequent, thorough mouth care.

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective? Relief from pain Increased ability to sleep Relief from constipation Reduced muscle spasticity

Reduced muscle spasticity

The nurse is preparing to perform the care of a patient's tracheostomy tube. Which of the following actions should the nurse perform during this procedure? Perform deep suctioning before and after the trach care. Remove the soiled twill tape after new tape has been put in place. Clean the stoma and the skin surrounding the stoma with chlorhexidine. Wash the inner cannula with soap and warm tap water if it is not disposable.

Remove the soiled twill tape after new tape has been put in place.

A triage nurse in the emergency department (ED) is on shift when a 4-year-old is carried into the ED by their grandparent. The child is not breathing, and the grandparent states the child was stung by a bee in a nearby park while they were waiting for the child's parent to get off work. Rapid onset of which condition would lead the nurse to suspect that the child is experiencing anaphylactic shock? Acute hypertension Neurologic compensation Respiratory distress Cardiac arrest

Respiratory distress

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? Risk for falls Risk for impaired skin integrity Risk for aspiration Decreased intracranial adaptive capacity

Risk for aspiration

A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis? Ineffective coping Diarrhea Risk for injury Noncompliance

Risk for injury

A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client? Safety Self-care Skin care Activity

Safety

A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client? Skin care Self-care Activity Safety

Safety

A nurse is assessing a client with Parkinson's disease. Which of the following would the nurse expect to find? Continuous tremors Gait with the body leaning backward Slowing of activity Muscle flaccidity

Slowing of activity

A nurse is providing morning care for a female patient who has been admitted for the treatment of a pressure ulcer. The patient is a quadriplegic following a spinal cord injury several years ago. While providing a bed bath to the patient, the nurse notes that many of her muscles are rigid and in a state of flexion. The nurse would document the presence of: Atonia Spasticity Flaccidity Tonus

Spasticity

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? Sphygmomanometer Suction machine with catheters Padded tongue blade Nasal cannula and oxygen

Suction machine with catheters

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation? Bilateral breath sounds present Copious mucous secretions Harsh cough Sudden restlessness

Sudden restlessness

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

Take measures to prevent injury.

The nurse is assessing a 6-year-old child in the emergency department (ED) who was brought in by the parent. The child was stung by a bee and is allergic to bee venom. The child is now having trouble breathing, and is vasodilated, hypotensive, and has broken out in hives. What does the nurse suspect is wrong with this child? The child is having an allergic reaction and going into anaphylactic shock. The child is having an allergic reaction and going into cardiogenic shock. The child is having an allergic reaction and going into neurogenic shock. The child is having an allergic reaction and going into obstructive shock.

The child is having an allergic reaction and going into anaphylactic shock.

When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? The most lethal injuries are often the most readily apparent. Most multiple trauma victims exhibit evidence of the trauma. The client is assumed to have a spinal cord injury until proven otherwise. Injuries have occurred to at least three distinct organ systems.

The client is assumed to have a spinal cord injury until proven otherwise.

The nurse checks the synchronizer switch before using a defibrillator to terminate ventricular fibrillation for what important reason? The delivered shock must be synchronized with the client's QRS complex. The defibrillator won't deliver a shock if the synchronizer switch is turned off. The defibrillator won't deliver a shock if the synchronizer switch is turned on. The shock must be synchronized with the client's T wave.

The defibrillator won't deliver a shock if the synchronizer switch is turned on.

The nurse is obtaining physician orders which include a pulse pressure. The nurse is correct to report which of the following? The difference between the systolic and diastolic pressure The difference between an apical and radial pulse The difference between the arterial and venous blood pressure The difference between an upper extremity and lower extremity blood pressure

The difference between the systolic and diastolic pressure

A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which explanation about the cause of the disorder? Regulatory mechanisms fail to halt the immune response. The immune system recognizes one's own tissues as "foreign." Excess cytokines cause tissue damage. The immune system recognizes one's own tissues as "self."

The immune system recognizes one's own tissues as "foreign."

Neurological level of spinal cord injury refers to which of the following? The best possible level of recovery The level of the spinal cord transection The highest level at which sensory and motor function is normal The lowest level at which sensory and motor function is normal

The lowest level at which sensory and motor function is normal

A patient with Parkinson's disease is experiencing an on-off syndrome. What does the nurse recognize that the patient's clinical symptoms will be? The patient will have a period when medication with levodopa will be unnecessary. The patient will have unilateral resting tremors and then will have a period of no tremors present. The patient will have periods of near immobility, followed by a sudden return of effectiveness of the medication. The patient will have a slow, shuffling gait and then will be able to move at a faster pace.

The patient will have periods of near immobility, followed by a sudden return of effectiveness of the medication.

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? To decrease cerebral edema To prevent seizure activity that is common following a TIA To determine the cause of the TIA To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow

To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow

Nursing students are reviewing information about Parkinson's disease in preparation for class the next day. The students demonstrate understanding of the material when they identify which of the following as a cardinal sign of this disorder? Select all that apply. Postural instability Bradykinesia Intellectual decline Rigidity Tremor

Tremor Rigidity Bradykinesia Postural instability

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

Turn the client to the side during a seizure and do not restrain movements

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

Turn the client to the side during a seizure and do not restrain movements

When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications from shock. What does this require the nurse to do? Provide the family with realistic expectations around the patient's prognosis. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment and response. Monitor for significant changes and evaluate patient outcomes on a scheduled basis, focusing on blood pressure and skin temperature. Keep the health care provider updated with the most accurate information because during treatment of shock, the nurse is often powerless to help.

Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment and response.

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.) Vital signs Visual acuity Urinary output Mental status Ability to perform range of motion exercises

Urinary output Mental status Vital signs

What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk? Administer prophylactic antibiotics for all patients at risk. Have patients wear masks in the health care facility. Use strict hand hygiene techniques. Insert indwelling catheters for incontinent patients.

Use strict hand hygiene techniques.

A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find? Tremors at rest Absent deep tendon reflexes Flaccid muscles Vision changes

Vision changes

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? ESR: 19 mm/hour Hemoglobin: 14.2 g/dL Potassium: 4.8 mEq/L WBC: 42,000/mm3

WBC: 42,000/mm3

Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including a high-protein diet and increased weight-bearing exercise. a low-cholesterol, low-protein diet and decreased aerobic exercise. a low-fat, low-cholesterol diet and increased exercise. eating fish no more than once a month.

a low-fat, low-cholesterol diet and increased exercise.

The nurse has instructed the family of a patient with stroke who has homonymous hemianopsia about measures to help overcome the deficit. The nurse determines that the family understands the measures to use if they a. Place objects in the patient's impaired field of vision .b. Approach the patient from the impaired field of vision. c. Remind the patient to turn the head to scan the lost visual field. d. Discourage the patient from wearing eyeglasses

c. Remind the patient to turn the head to scan the lost visual field.

A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is the priority a. Prepare to administer recombinant tissue plasminogen activator (rt-PA) b. Discuss the precipitating factors that caused the symptom c. Schedule for a stat computed tomography (CT) scan of the head. d. Notify the speech pathologist for an emergency consult.

c. Schedule for a stat computed tomography (CT) scan of the head.

The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided hemiparesis. Which action by the UAP requires the nurse to intervene? a. The assistant places a gait belt around the client's waist prior to ambulating. b. The assistant places the client on the back with the client's head to the side. c. The assistant places a hand under the right axilla to move up in bed. d. The assistant praises the client for attempting to perform ADLs.

c. The assistant places a hand under the right axilla to move up in bed.

The nurse plans to use all of the following positions in a patient with hemiplegia to prevent complications of immobility except: a. inserting a pillow in the axilla so the arm is away from the body. b. immobilizing the affected arm in a sling. c. keeping the arm in a dependent position. d. offloading the heels using a pillow.

c. keeping the arm in a dependent position.

A physician has ordered home health and physical therapy for an older adult who will be discharged home following an acute stroke. The nurse's discharge teaching should include instructions about: reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns. avoiding any social activity until the effects of the stroke have reversed. calling the home health nurse with any questions instead of bothering the physician and therapist. the daily exercise routine for the physical therapist to follow.

reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns.