Prep U: Exam 1 Adults 2 Questions

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following? a. Liver b. Pancreas c. Kidney d. Large intestine

a. liver rationale: Albumin is produced by the liver. Albumin is not produced in the pancreas, kidney, or large intestine.

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is: a. 48 mm Hg. b. 52 mm Hg. c. 68 mm Hg. d. 88 mm Hg.

b. 52 mm Hg rationale: To determine CPP, subtract the ICP from the mean arterial pressure (MAP). The MAP is derived using the following formula using the diastolic pressure (DP) and systolic pressure (SP): MAP = DP + 1/3(SP - DP) In this case MAP = 60 mm Hg + 1/3(90 mm Hg - 60 mm Hg) = 70 mm Hg CPP = MAP - ICP CPP = 70 mm Hg - 18 mm Hg = 52 mm Hg

The client is to receive a unit of packed red blood cells. What is the nurse's first action? a. check the label on the unit of blood with another registered nurse b. ensure that the intravenous site has a 20- gauge or larger needle c. observe for gas bubbles in the unit of packed red blood cells d. verify that the client has signed a written consent form

d. verify that the client has signed a written consent form rationale: All the options are interventions the nurse will do to ensure the blood transfusion is safe. The question asks about the first action of the nurse. The first action would be verifying that the client has signed a written consent form. Then, the nurse would ensure the intravenous site has a 20-gauge or larger needle. The nurse would proceed to obtain the unit of blood, check the blood with another registered nurse, and observe for gas bubbles in the unit of blood.

A client who is scheduled to have a modified radical mastectomy to remove an aggressive breast tumor is concerned about having agreed to the surgery before considering alternative options. Which statement is the nurse's best response? a. "Tell me more about your fears and concerns." b. "You have a very competent surgeon and you should move forward as planned." c. "You might want to consider a less invasive surgical procedure." d. "If I were you, I would consider a second opinion."

a. "tell me more about your fears and concern" rationale: The type of surgery recommended depends on the stage of the tumor and the client's informed decision about treatment options; a less invasive procedure may not remove all of the affected tissue. The client should be encouraged to express concerns. Surgery should not be performed until the client is comfortable with the scheduled procedure. The nurse should not share personal opinions with the client, but rather support the client in making the best decision.

An older adult client is to receive 2 units of packed red blood cells. During the transfusion of the first unit at 125 mL/hour, the client reports shortness of breath 30 minutes into the process. The client exhibits the vital signs shown in the accompanying table. What is the nurse's best intervention? a. slow the rate of the transfusion and obtain an order for furosemide b. administer oxygen through nasal cannula at 2 L/minute c. contact the health care provider and obtain an order for diphenhydramine (Benadryl) d. obtain blood and urine specimens for a transfusion reaction

a. slow the rate of the transfusion and obtain an order for furosemide rationale: The description is consistent with a client who is experiencing circulatory overload. The nurse is to slow the rate of the transfusion and administer a diuretic. Oxygen is administered with a prescription and for severe dyspnea. This option does not allow for the nurse to slow the transfusion. The nurse would still be administering the blood at the current rate of 125 mL/hour. Diphenhydramine (Benadryl) would be prescribed for an allergic reaction. Blood and urine specimens are obtained for acute hemolytic reactions.

A suspicious breast lump is noted on a mammogram. The client asks the nurse which diagnostic test confirms if the lump is cancerous or benign. Which response by the nurse is most correct? a. An ultrasound b. A biopsy c. A magnetic resonance imaging (MRI) d. A clinical breast exam

b. a biopsy rationale: To confirm whether a breast lump is cancerous or benign, a tissue sample must be obtained to examine the cells. Although an ultrasound, MRI, and clinical breast exam provides data on the characteristics of the lump, only examining the tissue can specifically identify if and what type of cancer is present.

A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching? a. "I'll watch my gums for bleeding when I brush my teeth." b. "I'll use an electric razor to shave." c. "I'll eat four servings of fresh, dark green vegetables every day." d. "I'll report unexplained or severe bruising to my doctor right away."

c. "I'll eat four servings of fresh, dark green vegetables every day" rationale: The client requires additional teaching if he states that he'll eat four servings of dark green vegetables every day. Dark, green vegetables contain vitamin K, which reverses the effects of warfarin. The client should limit his intake to one to two servings per day. The client should report bleeding gums and severe or unexplained bruising, which may indicate an excessive dose of warfarin. The client should use an electric razor to prevent cutting himself while shaving.

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? a. Encourage coughing and deep breathing. b. Position the client with the head turned toward the side of the brain tumor. c. Administer stool softeners. d. Provide sensory stimulation.

c. administer stool softeners rationale: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.

The nurse receives a call from the caregiver of a client with a spinal cord injury. The caregiver informs you that the client has a reddened, macerated area at the base of the sacrum. What would the nurse suspect is going on with the client? a. They are getting spinal contractures. b. They are gaining weight. c. They have the beginning of a pressure sore. d. They need a bath.

c. they have the beginning of a pressure sore rationale: Long-term complications include autonomic dysreflexia, pressure ulcers, respiratory infections, urinary and fecal impairment, spasticity and contractures, weight gain or loss, calcium depletion, urinary calculi, sexual dysfunction, and pain.

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? a. Lower back pain b. Burning sensation on urination c. Frequency of urination d. Fever and change in urine clarity

d. fever and change in urine clarity rationale: Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects the client has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition? a. fresh frozen plasma b. normal saline solution c. lactated ringer's solution d. packed red blood cells (PRBCs)

d. packed red blood cells (RBCs) rationale: In a trauma situation, the first blood product given is unmatched (O negative) packed RBCs. Fresh frozen plasma is commonly used to replace clotting factors. Normal saline or lactated Ringer's solution is used to increase volume and blood pressure; however, too much colloid will hemodilute the blood and doesn't improve oxygen-carrying capacity as well as packed RBCs do.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? a. Check the equipment. b. Contact the physician to review the care plan. c. Continue the assessment because no actions are indicated at this time. d. Document the reading because it reflects that the treatment has been effective.

a. check the equipment rationale: A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? a. Pupillary asymmetry b. Irregular breathing pattern c. Involuntary posturing d. Declining level of consciousness (LOC)

d. declining level of consciousness (LOC) rationale: With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

The nurse is providing care for a client who just discussed palliative care with the primary health care provider. The client's family member was also part of the discussion and asks the nurse, "I feel like this kind of treatment means we've given up on trying." How should the nurse respond? Choose the best option. a. "The goal of this type of care is to promote the best quality of life that is now possible." b. "This is your best option considering the end is near for the client. " c. "You are not giving up. Unfortunately the tumor has won the fight." d. "The prognosis for the client is poor, so it would be wasteful to provide any more aggressive treatment."

a. "the goal of this type of care is to promote the best quality of life that is now possible." rationale: Palliative care is a type of medical management that helps to improve the client's quality of life when cure is not possible. The nurse's best and most therapeutic response is to inform the family member that promoting optimal quality of life under the client's health circumstances is the goal of this type of care. The alternate options are presented by the nurse in a manner that is not therapeutic and does not offer the client and family member a more positive outlook on end of life.

A 50-year-old is diagnosed with stage II prostate cancer. The client is upset and verbalizes that he would rather die than have any surgery. Which is the best response by the nurse? a. "What concerns you most about having surgery?" b. "Your surgeon has performed this surgery many times." c. "How does your family feel about this decision?" d. "This surgery can cure you of cancer."

a. "what concerns you most about having surgery?" rationale: Being sympathetic and encouraging the client to express his concerns is a therapeutic response. This client may have concerns about the complications associated with the surgery and/or need additional information on newest techniques that improve outcomes. Explaining that the surgeon is competent does not address the concerns of this client. Family feelings are secondary to the concerns or the client. A cure of cancer is never a guarantee with any surgery.

A home care nurse is caring for a client with multiple myeloma. Which nursing interventions are appropriate for this client? Select all that apply. a. Delay position changes and bathing if the client is experiencing pain. b. Instruct the client to avoid activities that may cause injury. c. Assist with ambulation because exercise can worsen loss of calcium from the bone. d. Limit fluid intake. e. Monitor renal function

a. delay position changes and bathing if the client is experiencing pain; b. instruct the client to avoid activities that may cause injury; e. monitor renal function rationale: Pain can become quite severe. Delay position changes and bathing until analgesic has reached peak concentration level and the client is experiencing maximum pain relief. Safety is paramount because any injury, no matter how slight, can result in a fracture. The nurse assists the client with ambulation because immobility can worsen loss of calcium from the bone. The nurse provides up to 4000 mL of fluid to prevent renal damage from hypercalcemia and precipitation of protein in the renal tubules.

Which diagnostic test is indicated for postmenopausal bleeding? a. Endometrial biopsy b. Computed tomography c. Ultrasound d. Magnetic resonance imaging

a. endometrial biopsy rationale: For postmenopausal bleeding, an endometrial biopsy or D&C is indicated.

A nurse is caring for a female client following a motor vehicle accident resulting in paraplegia. The client is ready for discharge to home with her husband, who states, "I'm scared to carry her because I'm afraid I'll either hurt my back or drop her." What information will the nurse give the husband during discharge teaching? a. Ergonomic principles and body mechanics b. The importance of monitoring urinary elimination c. Nutritional changes for the client with paraplegia d. Signs and symptoms of chronic back pain that should be reported to the health care provider

a. ergonomic principles and body mechanics rationale: The husband's statement indicates a need for teaching in regard to client mobility and transfer techniques. Although urinary elimination, nutrition, and pain are components of care for clients with paraplegia, education about ergonomic principles and body mechanics is most appropriate at this time based on the husband's statement.

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

a. evaluation of gag reflex and ability to swallow rationale: Evaluation of the gag reflex and ability to swallow to prevent the risk of aspiration is an important nursing intervention. Monitoring vital signs, assistance with self-care, and frequent reorientation are important but are not the most important intervention.

When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? a. Health history, such as bleeding, fatigue, or fainting b. Menstrual history c. Age and gender d. Lifestyle assessments, such as exercise routines

a. health history, such as bleeding, fatigue, or fainting rationale: When assessing a client with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the client's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Age, gender, menstrual history, or lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.

Which term describes the percentage of blood volume that consists of erythrocytes? a. hematocrit b. differentiation c. erythrocyte sedimentation rate (ESR) d. hemoglobin

a. hematocrit rationale: Hematocrit is the percentage of blood volume consisting of erythrocytes. Differentiation is the development of functions and characteristics that differ from those of the parent stem cell. ESR is a laboratory test that measures the rate of settling of red blood cells (RBCs); an elevated rate is indicative of inflammation. Hemoglobin is the iron-containing protein of RBCs.

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

a. increased intracranial pressure rationale: Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. If the tumor is inoperable or has expanded despite treatment, increased intracranial pressure (ICP) is a major threat. In this scenario, there are no indications that volume either increasing or decreasing is an issue.

A client asks the nurse what PSA is. The nurse should reply that it stands for: a. prostate-specific antigen, which is used to screen for prostate cancer. b. protein serum antigen, which is used to determine protein levels. c. pneumococcal strep antigen, which is a bacteria that causes pneumonia. d. Papanicolaou-specific antigen, which is used to screen for cervical cancer.

a. prostate- specific antigen, which us used to prostate cancer rationale: PSA stands for prostate-specific antigen, which is used to screen for prostate cancer.

A nurse is teaching a male client to perform monthly testicular self-examinations. Which point is appropriate to make? a. Testicular cancer is a highly curable type of cancer. b. Testicular cancer is very difficult to diagnose. c. Testicular cancer is the number one cause of cancer deaths in males. d. Testicular cancer is more common in older men.

a. testicular cancer is a highly curable type of cancer rationale: Testicular cancer is highly curable, particularly when it's treated in its early stage. Self-examination allows early detection and facilitates the early initiation of treatment. The highest mortality rates from cancer among men are in men with lung cancer. Testicular cancer is found more commonly in younger, not older, men.

An oncology nurse is providing health education for a client who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia? a. The different leukemias all involve unregulated proliferation of white blood cells. b. The different leukemias all have unregulated proliferation of red blood cells and decreased bone marrow function. c. The different leukemias all result in a decrease in the production of white blood cells. d. The different leukemias all involve the development of cancer in the lymphatic system.

a. the different leukemias all involve unregulated proliferation of white blood cells rationale: Leukemia commonly involves unregulated proliferation of white blood cells. Decreased production of red blood cells is associated with anemias. Decreased production of white blood cells is associated with leukopenia. The leukemias are not characterized by their involvement with the lymphatic system.

Which of the following is the only definitive way to diagnose testicular cancer? a. Tissue biopsy b. Computed tomography of abdomen c. Ultrasound d. Lactate dehydrogenase levels

a. tissue biopsy rationale: Tissue biopsy is the only definitive way to determine whether cancer is present, and is performed at the time of surgery rather than as a part of the diagnostic workup, to reduce the risk of promoting spread of cancer. A computed tomography scan of the abdomen and pelvis is performed to determine the extent of the disease in the retroperitoneum and pelvis. Lactate dehydrogenase levels and ultrasound examination to determine the presence and size of the testicular mass may also be done.

The nurse identifies a nursing diagnosis of self-care deficit, bathing related to motor impairment and decreased cognitive function for a client with cerebral metastasis. Which outcome would the nurse most likely identify on this client's plan of care? a. Client demonstrates positive coping strategies. b. Client participates in daily hygiene activities with assistive devices. c. Client expresses feelings related to self-care ability. d. Client consumes adequate calories to meet energy needs.

b. client participates in daily hygiene activities with assistive devices rationale: The client has a self-care deficit related to bathing. Therefore, an appropriate outcome would address the client's participation in daily hygiene measures. Positive coping strategies would be appropriate for a nursing diagnosis associated with anxiety or fear. Verbalizing feelings about self-care ability would be more appropriate for a nursing diagnosis involving self-esteem or role function. Consuming adequate calories would be appropriate for a nursing diagnosis involving imbalanced nutrition, less than body requirements.

A male client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client's PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take? a. Continue with the present infusion rate of heparin. b. Consult with the physician about discontinuing heparin. c. Begin treatment with the prescribed warfarin (Coumadin). d. Increase the heparin infusion by 100 units per hour.

b. consult with the physician about discontinuing heparin rationale: Platelet counts may decrease with heparin therapy, and this client's platelet count has decreased. The client may have heparin-induced thrombocytopenia (HIT). Treatment of HIT includes discontinuing the heparin. The question asks about the most important action of the nurse and that is to consult with the physician about discontinuing heparin therapy. The nurse may continue with the current rate and should not increase the heparin dose until consulting with the physician. Warfarin is not administered until the platelet count has returned to normal levels.

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting? a. Decerebrate b. Decorticate c. Flaccidity d. Tonic clonic

b. decorticate rationale: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response; tonic clonic movements are seen with seizures.

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? a. Impaired physical mobility b. Ineffective breathing pattern c. Disturbed sensory perception (tactile) d. Dressing or grooming self-care deficit

b. ineffective breathing pattern rationale: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.

On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment? a. Radiation therapy b. Major surgery c. Chemotherapy d. None (At this advanced stage, ovarian cancer isn't treatable.)

b. major surgery rationale: Ovarian cancer usually requires aggressive treatment — initially, surgery. The client will require a total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomy, appendectomy, and lymphadenectomy. Radiation therapy is palliative for a client in this advanced stage of the disease. Chemotherapy also is largely palliative during this stage; however, prolonged remissions have been achieved in some clients.

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? a. Acetaminophen may be administered for aches. b. Observe for any signs of behavioral changes. c. A light meal may be eaten if desired. d. Follow up with regular physician is encouraged.

b. observe for any signs of behavioral changes rationale: All of the options are typical for a client being discharged with a concussion. The instruction that is emphasized is to observe for any signs of behavior changes, which may indicate an increase in the client's intracranial pressure. A concussion results in diffuse or microscopic injury to the brain with symptoms that may evolve.

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis? a. good b. poor c. excellent d. fatal

b. poor rationale: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing; it implies brain pathology, which is a poor prognostic sign. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response and the most severe neurologic impairment.

The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take? a. notify the client's healthcare provider b. stop the transfusion immediately c. remove the client's IV access d. assess the client's chest sounds and vital signs

b. stop the transfusion immediately rationale: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the client's vital signs, and notify the health care provider. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The client's IV access should not be removed.

Testicular cancer risk is highest for adolescents and men younger than age 35. To specifically address testicular cancer risk, a nurse should modify client teaching for male clients to include: a. physician visits. b. testicular self-examination. c. risk factors. d. family history.

b. testicular self- examination rationale: Testicular self-examination is a relatively simple technique that's extremely useful in detecting cancer-related testicular changes. Physician visits, risk factors, and family history are important to all clients, regardless of gender, and don't specifically address risk factors associated with testicular cancer.

A client who has had a left total mastectomy is about to view her surgical site for the first time. Which of the following would be most appropriate for the nurse to say? a. "You need to look at the incision so you can heal emotionally." b. "Don't be afraid. Everybody feels the same way." c. "Do you feel like you're ready to look at your incision now?" d. "Did you have reconstructive surgery when they removed your breast?"

c. "do you feel like you're ready to look at your incision now?" rationale: Looking at the surgical site for the first time is an emotional experience no matter how prepared the client may think she is. Therefore, the nurse needs to determine the client's readiness to view the site and provide gentle encouragement. Although the client needs to look at the surgical site to promote a positive body image and cope with the loss, telling the client that she must do so ignores how the client may be feeling and does not allow the client any choice. Telling the client not to be afraid also ignores how the client may be feeling. Asking about reconstructive surgery does nothing to help the client to prepare for what she might see.

A nurse is caring for a client with a history of GI bleeding, sickle cell anemia, and a platelet count of 22,000/μl. The client, who is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour, complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. For which administration route should the nurse question an order? a. Oral b. I.V. c. I.M. d. Subcutaneous (subQ)

c. I.M. rationale: A client with a platelet count of 22,000/μl bleeds easily. The nurse should avoid using the I.M. route because the area is highly vascular. The client may bleed readily when penetrated by a needle, and it may be difficult for the nurse to stop the bleeding. The client's existing I.V. access would be the best route, especially because I.V. morphine is effective almost immediately. Oral and subQ routes are preferred over I.M., but they're less effective for acute pain management than I.V.

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? a. Decreased heart rate b. Bradycardia c. Alteration in level of consciousness (LOC) d. Slurred speech

c. alteration in level of consciousness (LOC) rationale: The first sign of possible subdural hematoma is a change in LOC. Speech may be affected later as the client experiences continued reduction in oxygenation. Bradycardia and a decreased heart rate occur later if the condition isn't treated.

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? a. Flat b. Supine, with the head of the bed elevated 30 degrees c. Flat, except for logrolling as needed d. A head elevation of 90 degrees to prevent cerebral swelling

c. flat, except for logrolling as needed rationale: When caring for the client with a possible cervical spinal injury who's wearing a cervical collar, the nurse must keep the client flat to decrease mobilization and prevent further injury to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.

What is the most common type of brain neoplasm? a. Glioma b. Angioma c. Meningioma d. Neuroma

c. glioma rationale: Gliomas are the most common brain neoplasms, accounting for about 45% of all brain tumors. Angiomas account for approximately 4% of brain tumors. Meningiomas account for 15% to 20% of all brain tumors. Neuromas account for 7% of all brain tumors.

A nurse is caring for a client with a pituitary adenoma. Which laboratory test result suggests that a client has a corticotropin-secreting pituitary adenoma? a. High corticotropin and low cortisol levels b. Low corticotropin and high cortisol levels c. High corticotropin and high cortisol levels d. Low corticotropin and low cortisol levels

c. high corticotropin and high cortisol levels rationale: Pituitary adenomas secrete excess amounts of hormones, including adrenocortical-tropic hormone, resulting in Cushing syndrome, in which a corticotropin-secreting pituitary tumor causes high corticotropin and high cortisol levels. A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol level are associated with hypocortisolism. A primary defect in the adrenal glands causes low corticotropin and high cortisol levels.

A client is suspected of having a spinal cord tumor. What diagnostic study would the nurse include in the client teaching? a. Positron emission tomography scan b. Chest radiology c. Magnetic resonance imaging scan d. Complete blood count

c. magnetic resonance imaging scan rationale: The magnetic resonance imaging scan is the most commonly used and the most sensitive diagnostic tool for spinal cord tumors. A positron emission tomography scan helps determine how organs and tissues are working. A chest radiology study is used to examine structures in the chest. A complete blood count will not aid in diagnosis of a spinal cord tumor.

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? a. Giving him a barbiturate b. Placing him on mechanical ventilation c. Performing a lumbar puncture d. Elevating the head of his bed

c. performing a lumbar puncture rationale: The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP.

Corticosteroids are used in the management of brain tumors to a. prevent extension of the tumor. b. facilitate regeneration of neurons. c. reduce cerebral edema. d. identify precise location of the tumor.

c. reduce cerebral edema rationale: Corticosteroids may be used before and after treatment to reduce cerebral edema and promote a smoother, more rapid recovery. Corticosteroids do not prevent extension of the tumor or facilitate regeneration of neurons. Stereotactic procedures identify the precise location of the tumor.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? a. Related to visual field deficits b. Related to difficulty swallowing c. Related to impaired balance d. Related to psychomotor seizures

c. related to impaired balance rationale: A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction.

To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard? a. The client is maintained on strict bed rest. b. The head of the bed is at a 30-degree angle. c. The client receives a complete bed bath each morning. d. The nurse checks the applicator's position every 4 hours.

c. the client receives a complete bed bath each morning rationale: The client shouldn't receive a complete bed bath while the applicator is in place. In fact, she shouldn't be bathed below the waist because doing so puts the nurse at risk for radiation exposure. During this treatment, the client should remain on strict bed rest, but the head of her bed may be raised to a 30- to 45-degree angle. The nurse should check the applicator's position every 4 hours to ensure that it remains in the proper place.

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count? a. Anemia b. Leukopenia c. Thrombocytopenia d. Neutropenia

c. thrombocytopenia rationale: A normal platelet count is 140,000 to 400,000/mm3 in adults. Chemotherapeutic agents produce bone marrow depression, resulting in reduced red blood cell counts (anemia), reduced white blood cell counts (leukopenia), and reduced platelet counts (thrombocytopenia). Neutropenia is the presence of an abnormally reduced number of neutrophils in the blood and is caused by bone marrow depression induced by chemotherapeutic agents.

Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia? a. Have the client use a soft toothbrush and electric razor, avoid using enemas, and watch for signs of bleeding. b. Put on a mask, gown, and gloves when entering the client's room. c. Provide a clear liquid, low-sodium diet. d. Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing.

d. eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing rationale: Neutropenia occurs when the absolute neutrophil count falls below 1,000/mm3, reflecting a severe risk of infection. The nurse should provide a low-bacterial diet, which means eliminating fresh fruits and vegetables, avoiding invasive procedures such as enemas, and practicing frequent hand washing. Using a soft toothbrush, avoiding straight-edged razors and enemas, and monitoring for bleeding are precautions for clients with thrombocytopenia. Putting on a mask, gown, and gloves when entering the client's room are reverse isolation measures. A neutropenic client doesn't need a clear liquid diet or sodium restrictions.

A client, age 42, visits the gynecologist. After examining the client, the physician suspects cervical cancer. The nurse reviews the client's history for risk factors for this disease. Which history finding is a risk factor for cervical cancer? a. Onset of sporadic sexual activity at age 17 b. Spontaneous abortion at age 19 c. Pregnancy complicated with eclampsia at age 27 d. Human papillomavirus infection at age 32

d. human papillomavirus infection at age 32 rationale: Like other viral and bacterial venereal infections, human papillomavirus is a risk factor for cervical cancer. Other risk factors for this disease include frequent sexual intercourse before age 20, multiple sex partners, and multiple pregnancies. A spontaneous abortion and pregnancy complicated by eclampsia aren't risk factors for cervical cancer.