questions for med surg test 3

A nurse is teaching a client who is going to have a bone scan. which of the following statements should the nurse include? A. you will receive injection of a radioactive isotope when the scanning procedure begins B. you will be inside a tube-like structure during the procedure C. you will need to take radioactive precautions with your urine for 24 hours after the procedure D. you will have to urinate just before the procedure

nswer: D you will have to urinate just before the procedure -the nurse should inform the client that he will need to urinate prior to the procedure. an empty bladder promotes visualization of the pelvic bones

An unconscious patient with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? A establishing an airway B replacing blood loss C stopping bleeding from open wounds D checking for a neck fracture

A establishing an airway

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? select all that apply. A systolic blood pressure B urine output C breath sounds D cerebral perfusion pressure

A systolic blood pressure D cerebral perfusion pressure

The nurse is planning for care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following are appropriate nursing actions? Select All That Apply. A. Implement seizure precautions. B. Perform neurological checks four times a day. C. Administer morphine for the report of neck and generalized pain. D. Turn off room lights and television. E. Monitor for impaired extraocular movements. F. Encourage the client to cough frequently.

A. Implement seizure precautions. D. Turn off room lights and television. E. Monitor for impaired extraocular movements.

which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Selecta ll that apply A. keep the cast clean and dry B. allow the cast 24-72 hours to dry C. keep the cast and extremity elevated D. expect tingling and numbness in the extremity E. use a hair dryer set on a warm to hot setting to dry the cast F. use a soft padded object that will fit under the cast to scratch the skin under the cast

A. keep the cast clean and dry B. allow the cast 24-72 hours to dry C. keep the cast and extremity elevated

the nurse is caring for a client being traded for fat embolus after multiple fractures. which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? A. clear mentation B. minimal dyspnea C> oxygen saturation of 85% D. arterial oxygen level of 78 mmHg

A. clear mentation

a nurse is caring for a client who experienced a cervical spin injury 3 months ago. the nurse should plan tot implement which of the following types of bladder managementnt methods A. condom catheter B. intermittent urinary catheterization C. credes method D. indwelling urinary catheter

A. condom catheter

a client is being discharge to home after application of a plaster leg cast. which statement indicates that the client understands proper care of the cast? A. i need to avoid getting the cast wet B. i need to cover the casted leg with warm blankets C. i need to use my fingertips to lift and move my leg D> i need to use something like a padded coat hanger end to scratch under the cast if it itches

A. i need to avoid getting the cast wet

a nurse is caring for a client who was recently admitted to the emergency department following a head on motor vehicle crash. the client is unresponsive, has spontansoue respirations of 22/min and has a laceration on his forehead that is bleeding. which of the following is the priority nursing acton at this time ? A. keep neck stabilized B. insert ng tube C. monitor pulse and blood pressure frequently D. establish IV access and start fluid replacement

A. keep neck stabilized

What nursing care should be provided for the patient WITH MENINGITIS ?

Airway O2 Vitals Neuro check Give medications Monitor I and O- SIADH

What medical management should the nurse anticipate for the patient WITH MENINGITIS ?

Antipyretics Anti- seizer Antibiotics Analgesics

Dobutamine is used to treat a client experiencing cardiogenic shock. Nursing intervention includes: A Monitoring for fluid overload. B Monitoring for cardiac dysrhythmias. C Monitoring respiratory status. D Monitoring for hypotension.

B Monitoring for cardiac dysrhythmias.

Nurse is giving hydralazine hydrochloride (apresoline) to a patient with autonomic dysreflexia. which of the following findings indicates that the medication is effective? A patient's muscle spasms subside B patient's blood pressure declines C intensity of patient's seizures decline D patient states they feel better

B patient's blood pressure declines drug given is hydrazine and labetolol to lower hypertension

a client has clear fluid leakage from the nose following a basilar skull fracture. which finding would alert the nurse that cerebrospinal fluid is present? A. fluid is clear and tests negative for glucose B. fluid is grossly blood in appearance and has a pH of 6 C. fluid clumps together on the dressing and has a pH of 7 D. fluid separates into concentric rings and tests positive for glucose

D. fluid separates into concentric rings and tests positive for glucose

A client with increased ICP is prescribed the following tests. The nurse would clarify which test with the physician? A. MRI B. LP C. CT Scan. D. Cerebral angiography

B. LP if you did this you could kill them MRI is more for the spine but not bad to do you would never do an LP first, you do an LP as last resort to rule out infection

the nurse is assessing the motor function of an unconscious client. the nurse should plan to use which technique to test the clients peripheral response to pain? A. Sternal rub B. Nail bed pressure C. pressure on the orbital rim D. squeezing of the sternocleidomastoid muscle

B. Nail bed pressure

The nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? Select All That Apply. A. Monitor for bradycardia B. Provide an emesis basin at the bedside. C. Administer antipyretic medication as prescribed. D. Perform a skin assessment. E. Keep the head of the bed flat.

B. Provide an emesis basin at the bedside. C. Administer antipyretic medication as prescribed. D. Perform a skin assessment.

the nurse has completed discharge instructions for a client with application of a halo device. which action indicates that the client needs further clarification of the instructions? A. uses a draw for drinking B. drives only during the daytime C. uses caution because the device alters balance D. washing the skin daily under the lambs wool liner of the vest

B. drives only during the daytime

the nurse is caring for the client with increased intracranial pressure. the nurse would note which trend in vital sings if the intracranial pressure is rising? A. increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B. increasing temperature, decreasing pulse, decreasing respirations. increasing blood pressure C. decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

B. increasing temperature, decreasing pulse, decreasing respirations. increasing blood pressure

the nurse is assessing the motor function of an unconscious client. the nurse should plan to use which techniques to test the clients peripheral response to pain? A. sternal rub B. nail bed pressure C. pressure on the orbital rim D. squeezing of the sternocleidomastoid muscle

B. nail bed pressure

the nurse has conducted teaching with a client in an arm cast about the s/s of compartment syndrome. the nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? A. cold, bluish colored fingers B. numbness and tingling in the fingers C. pain that increases when the arm is dependent D. pain that is out of proportion to the severity of the fracture

B. numbness and tingling in the fingers

Client preparing for lumbar puncture. Nurse will assist client into which position for procedure? A.Prone, slight Trendelenburg position B.Prone, pillow under abdomen C.Side-lying with legs pulled up and head bent down onto chest. D.Side-lying with pillow under hip

C. Side-lying with legs pulled up and head bent down onto chest. -have to curl them up to open the spine

the nurse is evaluating the status of a client who had a craniotomy 3 days ago. which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A. negative kerning sign B. absence of nuchal rigidity C. a positive brudzinski sign D. a glasgow coma scale score of 15

C. a positive brudzinski sign

a client has sustained a closed fracture and has just had a cast applied to the affected arm. the client is complaining of intense pain. the nurse elevates the limb, applies an ice bag and administers an analgesic with little relief. which problem may be causing this pain? A. infection under the cast B. the anxiety of the client C. impaired tissue perfusion D. the recent occurrence of the fracture

C. impaired tissue perfusion -most pain associated with fracture can be minimized with rest, elevation, application of cold, and administration of analgesics -pain that is not relieved by these measures should be reported to the health care provider because pain unrelieved by medications and other measures may indicate neuromuscular compromise. because this is a new closed fracture and cast, infection would not have had time to set in

the nurse is assessing the casted extremity of a client. which sign is indicative of infection? A. dependent edema B. diminished distal pulse C. presence of a "hot spot" on the cast D. coolness and pallor of the extremity

C. presence of a "hot spot" on the cast

Nurse admitting post-craniotomy client from PACU. Client's incision is supratentorial, nurse will assist client into which position? A.Head of bed flat B.Supine C.Elevate HOB to 30 degrees. D.Lying on operative side

C.Elevate HOB to 30 degrees.

Client admitted to PACU following craniotomy for drainage of epidural hematoma. Client is snoring loudly and has diminished breath sounds bilaterally. What action should the nurse take immediately? A.Place oxygen and raise HOB B.Place oxygen and call anesthesiologist C.Tilt client's head back and move jaw forward. D.Insert nasal airway

C.Tilt client's head back and move jaw forward. -because you shouldn't leave the client -want to move the tongue away form the occlusion

What diagnostic and lab tests are used to confirm the diagnosis of meningitis?

CAT Scan Lumbar puncture

A client with a head injury regains consciousness after several days. Which of the following nursing statements is most appropriate as the patient awakens? A "i'll get your family" B "Can you tell me your name and where you live?" C "I'll bet you're a little confused right now." D "You are in the hospital. You were in an accident and unconscious."

D "You are in the hospital. You were in an accident and unconscious."

the nurse is conducting a health screening for osteoporosis. which client is at greatest risk of developing this disorder? A. A 25 year old woman who jogs B. A 36 year old man who has asthma C. A 70 year old man who consumes excess alcohol D. A sedentary 65 year old woman who smokes ciggs

D. A sedentary 65 year old woman who smokes ciggs

the nurse is assessing the adaptation of client to changes in functional status after a stroke (brain attack). which observation indicates to the nurse that the client is adapting most successfully? A. gets angry with family if they interrupt a task B. experiences bouts of depression and irritability C. has difficulty using modified feeding utensils D. consistently uses adaptive equipment in dressing self

D. consistently uses adaptive equipment in dressing self

a client recovering from a head injury is participating in care. the nurse determines that the client understands measures to prevent elections in intracranial pressure if the nurse observes the client doing which activity? A. blowing the nose B. isometric exercise C. coughing vigorously D. exhaling during repositioning

D. exhaling during repositioning

a client recovering from a head injury is participating in care. the nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? A. blowing the nose B. isometric exercises C. coughing vigorously D. exhaling during repositioning

D. exhaling during repositioning

To what room should the charge nurse assign the patient WITH MENINGITIS ?

Private isolation room Face mask- special for droplet precautions

What additional signs and symptoms could a patient diagnosed with bacterial meningitis exhibit?

Rash Stiff neck Headache LOC Prositive Kernig's and Brudzinski's Sign

Client admitted to PACU following craniotomy for drainage of epidural hematoma. Client is snoring loudly and has diminished breath sounds bilaterally. What action should the nurse take immediately? Place oxygen and raise HOB Place oxygen and call anesthesiologist Tilt client's head back and move jaw forward. Insert nasal airway

Tilt client's head back and move jaw forward.

a nurse si caring for a client who just experienced a generalized seizure. which of the following actions should the nurse perform first? A.keep the client in a side lying position B.document the duration of the seizure C.reorient the client to the environment D.provide client hygiene

answer: A

a nurse is caring for a client who experienced aa cervical spin injury 24 hours ago. which of the following types of prescribed medication should the nurse clarify with the provider? A. steroid B. plasma expanders C. H2 antagonists D. muscle relaxants

answer: muscle relaxants -the nurse should clarify with the provider the need for the client to receive relaxants. the client will not experience muscle spams until after the spinal shock has resolved, making muscle relaxants unnecessary at this time

a nurse is caring for a client who has a C4 spinal cord injury. the nurse should recognize the client is at greatest risk for which of the following complicaitons? A. neurogenic shock B. paralytic ileus C. stress ulcer D. respiratory compromise

answer: respiratory compromise -when using the ABC approach the client care, the priority complication is respiratory compromise

a nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. which of the following should the nurse include in the teaching plan (slect all that apply) A. encourage complete autologous blood donation B. sit in a low reclining chair C. instruct the client to roll onto the operative hip D. use an abductor pillow when turning the client E. perform isometric exercises

answer:A, D, E

an unconscious client assumes a decerebrate posture in response to any noxious stimuli. when drawing a blood sample, the nurse should expect the client to: A. rigidly extend all four extremities B. internally flex the arms and extend the legs C. tightly curl into a fetal position D. internally rotate the arms and legs

answer:A. rigidly extend all four extremities -the client in a decerebrate position extends all four extremities rigidly. in addition the wrists are externally rotates. decerebrate posturing indicates severe brain stem injury and poor prognostic sign

a nurse in the emergency department is planning care for a client who has a right hip fracture. which of the following immobilization device should the nurse anticipate in the plan of care? A. skeletal traction B. bucks traction C. halo traction D. bryants traction

answer:B. bucks traction

a nurse is assessing a client who reports severe headache and a stiff neck. the nurses assessment reveals positive kernels and brudzinskis signs. which of the following actions should the nurses perform first? A. administer antibiotics B. implement droplet precautions C. initiate IV access D. decrease bright lights

answer; B implement droplet precautions

a nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. vital signs include blood pressure 220/1100 and apical heart rate 54 BPM. which of the following actions should the nurse do first A. notify the provider B. sit the client upright in bed C. check the urinary catheter for blockage D. administer anti-hypertensive meds

answer; B sit the client upright in bed -the greatest risk to the client is experiencing a cerebrovascular accident (stroke0 secondary to elevated blood pressure caused by autonomic dysreflexia. the first action the nurse should take is to elevate the head of the bed until the client is an upright positon, which shoulder lower the blog pressure secondary to postural hypotension

a nurse is reviewing trigger factos that can cause seizures with a client who has na new diagnosis of generalized seizures. which of the following information should the nurse include in this review? (select all that apply) A. avoid overwhelming fatigue B. remove caffeinated products from the diet C. limit looking at flashing lights D. perform aerobic exercise E. limit episodes of hypoventilation F. use of aerosol hairspray is recommended

Answer: A, B, C

the nurse is assigned to care for a client with complete right sided hemiparesis. which characteristics are associated with this condition? Select all that apply A. the client is aphasic B. the client has weakness in the face and tongue C. the client has weakness on the right side of the body D. the client has complete bilateral paralysis of the arms and legs E. the client has lost the ability to move the right arm but is able to walk independently F. the client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance

A. the client is aphasic B. the client has weakness in the face and tongue C. the client has weakness on the right side of the body

Patient with head injury. Which of the following are manifestations of Increased ICP? SELECT ALL THAT APPLY A.Headache. B.Tachycardia C.Hypotension DPupillary changes. E.Abnormal posturing.

A.Headache. DPupillary changes. E.Abnormal posturing. patient will usually be bradycardia and hypertension... think about that lady at sloan!! her pressure was 215/100 this all means that the patient will need a cat scan

Client with diagnosis of SIADH. The nurse would expect to see what laboratory finding? A.Serum sodium 125. B.Serum potassium 2.7 C.Serum glucose 250 D.Serum chloride 110

A.Serum sodium 125. sodium is always low in SIADH ...it is high in DI!

the nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. which measures should the nurse include in planning care for the client's safety? Select all that apply A. padding the side rails of the bed B. placing an airway at the bedside C. placing the bed in the high position D. putting a padded tongue blade at the head of the bed E. placing oxygen and suction equipment at the bed side F. having intravenous equipment ready for insertion of an intravenous catheter

A. padding the side rails of the bed B. placing an airway at the bedside E. placing oxygen and suction equipment at the bed side F. having intravenous equipment ready for insertion of an intravenous catheter

a nurse is planning care for a client ho will undergo an electromyography (EMG) which of the following actions should the nurse include in the plan of care?(select all that apply) A. assess for bruising B. apply ice to insertion sites C. determine whether the client takes a muscle relaxant D. instruct the client to flex her muscles during needle insertion E. expect swelling, redness, and tenderness at the insertion site

Answer: A, B, C, D

a nurse is assessing a client who has seizure disorder. the client reports he thinks he is out to have a seizure. which of the following actions should the nurse implement (select all that apply) A. provide privacy B. ease the client to the flor if standing C. move furniture away from the client D. loosen the clients clothing E. protect the clients head with padding F. restrain the client

Answer: A, B, C, D, E

a nurse is teaching a client how to manage an external fixation device upon discharge which of the following statements by the client indicates an understanding of the teaching? (select all that apply) A. i will clean the pin twice a day B. i will use a separate cotton swab for each pin C. i will report loosening of the pins to my doctor D. i will move my leg by lifting the device in the middle E. i will report increased redness at the pin sites

Answer: A, B, C, E

A nurse is planning care for a client who is postopetavie following an arthroscopy of the knee. which of the following actions should the nurse take? select all that apply A. assess color and temperature of the extremity B. apply warm compresses to incision sites C. place pillows under the extremity D. administer analgesic medicaiton E. assess pulse and sensation in the foot

Answer: A, C, D, E

a nurse is performing health screening at a health fair. which of the following clients are at risk for osteoprosis? (select all that apply) A. a 40 year old client who takes prednisone for asthma B. a 30 year old client who jogs 3 miles daily C. a 45 year old client who takes phenytoin for seizures D. a 65 year old client who has sedentary lifestyle E. a 70 year old client who has smoked for 50 year s

Answer: A, C, D, E

A nurse is completing pre-operative teaching for a client who is undergoing an arthroscopy to repair a shoulder injury. which of the following statements should the nurse include(select all that apply) A. avoid damage or moisture to the cast on your arm B. inspect you in scion daily for indicates of infection C. apply ice packs to he area for the first 24 hours D. keep your arm in a dependent position E. perform isometric exercises

Answer: B, C, E

a nurse is assessing a client who has experienced a left hemispheric stroke. which of the following is an expected findings? A. impulse control difficulty B. poor judgement C. inability to recognize familiar object D. loss of depth perception

Answer: C

A nurse is reviewing the health record of a client who is to undergo totally joint arthorplasty. the nurse should recognize which of the following findings as a contraindication tho this procedure? A. age 78 years B. history of cancer C. previous joint replacement D. bronchitis 2 weeks ago

Answer: D bronchitis 2 weeks ago -the client who recently had bronchitis or a recent infection can cause micro-organisms to migrate to the surgical area and cause the prosthesis to fail

a nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. which of the following is the priority assessment? A. glasgow coma scale B. cranial nerve function C. oxygen saturation D. pupillary response

Answer: oxygen saturation

the nurse is caring for the client with increased intracranial pressure. the nurse would note which trend in vital signs if the intracranial pressure is rising? A. increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B. increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure C. decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

B. increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

the nurse is caring for a client who begins to experience seizure activity while in bed. which action by the nurse is contraindicated? A. loosening restrictive clothing B. restraining the clients limbs C. removing the pillow and raising padded side rails D. positioning the client to the side, if possible, with the head flexed forward

B. restraining the clients limbs

the nurse is evaluating the pin sites of a client in skeletal traction. the nurse would be least concerned with which finding? A. inflammation B. serous drainage C. pain at pin site D. purulent drainage

B. serous drainage

Client is having tonic-clonic seizure. Nurse should take which of the following actions? SELECT ALL THAT APPLY A.Restrain client B.Maintain airway. C.Turn client to side. D.Place tongue blade in mouth E.Protect client from injury.

B.Maintain airway. C.Turn client to side. E.Protect client from injury.

Nurse is assessing neuro status of client who had craniotomy 3 days ago. Nurse should notify surgeon immediately if client exhibits which of the following? A.Pupils equal and reactive at 4 mm in size B.Pain with forward flexion of the neck onto the chest. C.Mild headache relieved by codeine sulfate D.Disorientation to date

B.Pain with forward flexion of the neck onto the chest. -pain in the neck means nucoregidity? could have caused an infection during surgery

A patient in a motor vehicle crash diagnosed with SDH on CT scan. After the scan the BP starts to drop and pulse becomes rapid. the nurse should: A place client in reverse trendelenburg B perform neuro assessment C assess for other areas of bleeding D check LOC every hour

C assess for other areas of bleeding brain-hypertension -if they don't have hypertension DO not look at the head, look below like cord or abdomen bleeding-hypotension

Which activity should the nurse encourage the patient to avoid when there is a risk for intracranial pressure(ICP)? A deep breathing B turning C coughing D passive range-of-motion exercises

C coughing coughing will increase the ICP

a client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurses the cerebrospinal fluid is present? A. fluid is clear and tests negative for glucose B. fluid is grossly bloody in appearance and has a pH of 6 C. fluid clumps together on the dressing and has a pH of 7 D. fluid separates into concentric rings and tests positive for glucose

D. fluid separates into concentric rings and tests positive for glucose

a client with a spinal cord injury is prone to experiencing autonomic dysreflexia. the nurse should avoid which measure to minimize the risk of occurrence? A. strict adherence to bowel retraining program B. keeping the linen wrinkle-free under the client C. preventing unnecessary pressure on the lower limbs D. limiting bladder cauterization to once every 12 hours

D. limiting bladder cauterization to once every 12 hours the most frequent cause of autonomic dysreflexia is a distended bladder. straight catheterization should be done every 4-6 hours and foley catheters should be checked frequently to prevent kinks in the tubing

a client with a hip fractures asks the nurse why bucks (extension) traction is being applied before surgery? the nurse provides a response based on which purpose of bucks (extension) traction? A. allows bony healing to being before surgery B. provides rigid immobilization of the fracture site C. lengthens the fractured leg to prevent severing of blood vessels D. provide comfort by reducing muscle spasms and provides fracture immobilization

D. provide comfort by reducing muscle spasms and provides fracture immobilization bucks traction is type of skin traction often applied after hip fracture before the fracture is reduced in surgery. traction reduces muscle spasms and helps immobilize the fracture. traction does not allow for bony healing to being or provide rigid immobilization. traction does not lengthen the leg for the purpose of preventing blood vessel severance.

the nurse is one of several people who witnessed a vehicle hit a pedestrian at fairly low speed on a small street. the victim is dazed and tries to get up. the leg appears fractured. which intervention should the nurse take? A. try to reduce the fracture manually B. assist the victim to get up and walk to the sidewalk C. leave the victims for a few moments to call an ambulance D. stay with the victims and encourage the person to remain still

D. stay with the victims and encourage the person to remain still

the nurse has instructed the family of a client with a stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. which statement suggests that the family understands the measures to use when caring for the client? A. We need to discourage him from wearing eyeglasses B. we need to place objects in his impaired field of vision C. we need to approach him form the impaired field of vision D. we need to remind him to turn his head to scan the lost of visual field

D. we need to remind him to turn his head to scan the lost of visual field

Client is 12 hours postoperative craniotomy. Nurse observes and increase in urine output up to 220cc/hour for the past 2 hours. Increased UO may be indicative of ... A.Improved renal function B.Hypovolemic shock C.Normal response post-craniotomy D.Diabetes Insipidus.

D.Diabetes Insipidus.

Client sustained closed head injury. Nurse assess for which early sign of impending neurological deterioration? A.Loss of corneal reflex B.Increased visual acuity C.Bilateral pupil equality and reactivity D.Ipsilateral pupil dilation.

D.Ipsilateral pupil dilation......pupils should not be dilated

Abnormal extension (Decerebrate) posturing is characterized by which of the following? A.Extension of extremities and pronation of the arms B.Flexion of extremities and pronation of arms C.Upper extremity flexion with lower extremity extension D.Upper extremity extension with lower extremity flexion.

D.Upper extremity extension with lower extremity flexion.

the nurse is admitting a client with multiple trauma to the nursing unit. the client has a leg fracture and had a plaster cast applied. which would be best for the casted leg? A. flat for 12 hours, then elevated for 12 hours B. elevated for 3 hours and then flat for 1 hour C. flat for 3 hours and then elevated for 1 hour D> elevated on pillows continuously for 24-48 hours

D> elevated on pillows continuously for 24-48 hours

The body temperature of an unconscious patient is never taken by which route? Axillary Mouth Rectal Tympanic

Mouth

A nurse is reading the results of a lumbar puncture performed on a client suspected too having bacterial meningitis. which of the following findings should the nurse recognize as being consistent with this diagnosis? A. elevated glucose B. elevated protein C. presence of red blood cells D. presence of D dimer

answer is B elevated protein -an LP is a diagnostic test in which CSF is extracted for examination. typically CSF has a higher proportion of glucose than protein. an elevated protein level is consistent finding with meningitis

a nurse is assessing a client who has casted compound fracture of the femur. which of the following findings is a manifestation of a fat emoji? A. altered mental status B. reduced bowel sounds C. swelling of the toes distal to the injury D. pain with passive movement of the foot distal to the injury

answer: A

a nurse is planning care for a client who has a spinal cord injury involving a T12 fracture 1 week ago. the client has no muscle control of the lower limbs, bowel, or bladder. which of the following should be the nurses highest priority? A. prevention of further damage of the spinal cord B. prevention of contracature son the lower extremities C. prevention sfo skin breakdown of areas that lack sensation D. prevention of postural hypotension when placing the client in a wheelchair

answer: A

a nurse is caring for a client who has global aphasia (both receptive and expressive). which of the following should the nurse include in the clients plan of care? (select all that apply) A. speak to the client at a slower rate B. assist the client to use flash cards with pictures C. speak to the client in a loud voice D. complete sentences that client cannot finish E. give instructions one step at a time

answer: A, B , E

a nurse is planning care for a client who has dysphagia and a new dietary prescription. which of the following should the nurse include in the plan of care? select all that apply A. have suction equipment available for use B. feed the client thickened liquids C. place the food on the unaffected side of the clients mouth D. assign an assertive persona to feed the client slowly E. teach the client to swallow with her neck flexed

answer: A, B, C, D

a nures is planning discharge teaching on home safety for an older adult client who has osteoporosis. which of the following information should the nurse include in the teaching? (slect all that apply) A. remove the throw rugs in walkways B. use prescribed assistive devices C. remove the clutter from the environment D. walk with caution on icy surfaces E. maintain lighting of doorway areas

answer: A, B, C, E

nurse is caring for a client who has experienced a right hemispheric stroke. which of the following are expected findings? select all that apply A. impulse control difficulty B. left hemiplegia C. loss of depth perception D. aphasia E. lack of situation awareness

answer: A, B, C, E

A nurse is admitted a client to the orthopedic unit following a toal knee arthroplasty. which of the following actions by the nurse are approparatie? (select all that apply A. check continuous passive motion device setting B. palpate dorsal pedal pulses C. place pillow behind the knee D. elevate heels off bed E. apply heat therapy to incision

answer: A, B, D

a nures in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. which of the following assessment findings are indicative of increased ICP (select all that apply) A. headache B. dilated pupils C. tachycardia D. decorticate posturing E. hypotension

answer: A, BD decorticate or decorate posturing is a fading associated with increased ICP

a nurse is assessing for the presence of brudzinski's sign in a client who has suspected meningitis. which of the following actions should the nurse take when performing this technique? (select all that apply) A. place client in supine position B. flex clients hip and knee C. place hands behind the clients neck D. bend clients head toward chest E. straighten the clients flexed leg at the knee

answer: A, C, D

A nurse is assessing a client who had an external fixation device applied 2 hours ago for a fracture of the left tibia and fibula. which of the following findings is a manifestation of compartment syndrome (select all that apply) A. increase pain when the clients left foot is passively moved B. capillary refil of 3 seconds on the clients left toes C. hard, swollen muscle in the client left leg D. burning and tingling of the clients left foot E. client report of minimal pain relief following a second dose of opioid medication

answer: A, C, D, E

a nurse is planning discharge teaching for a client who had a total hip arthroplasty. which of the following should the nurse include in teaching? (select all that apply) A. clean the incision daily with soap and water B. turn the toes inward when sitting or lying C. sit in a straight backed armchair D. bend at the waist when putting on socks E. use a raised toilet seat

answer: A, C, E

a nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). which of the following actions should the nurses plan to take? (select all that apply) A. implement seizure precaution B. perform neurological checks four times a day C. administer morphine for the report of neck and generalized pain D. turn off room lights and television E. monitor for impaired extra ocular movement F. encourage the client to cough frequently

answer: A, D, E

a nurse is caring for a client who has increased ICP and new prescription for mannitol. for which of the following adverse effects should the nurse monitor? A. hyperglycemia B. hyponatremia C. hypervolemia D. oliguria

answer: B

a nurse is caring for a client who has left homonymous hemianopsia. which of the following is an appropriate nursing intervention? A. teach the client to scan to the right to see objects on the right side of her body B. place the bedside table on the right side of the bed C. orient the client to the food on her plate using the clock method D. place the wheelchair on the clients left side

answer: B

a client is transferred to a rehabilitation center 3 weeks following a cerebrovascular accident. the clients CVA involved the left side of the brian. which of the following goals should the nurse anticipate including in the clients rehabilitation program? A. improving left side motor function B. establishing the ability to communicate effectively C. learning to control impulsive behavior D. keeping the left side of the body safe

answer: B establishing the ability to communicate effectively -the left hemisphere of the brain is usually the dominate side and is responsible of language. this is always true for right handed clients and for the majority of th left handed clients. since the client had a left hemisphere CVA, the nurse should initiate the the client will have some degree of aphasia and require speech therapy to establish communication -a client who had a left hemisphere CVA will demonstrate hemiplegia of the right side of the body

a nurse is providing care for a client who has a vertebroplasty of the thoracic spine. which of the following is an appropriate action by the nurse? A. apply heat to the puncture site B. place the client in a supine position C. turn the client every hour D. ambulate the client within the fro hour of the E. procedure

answer: B place the client in supine position

a nurse is planning care for a client who has bacterial minigitsi. which of the following actions should the nurse include in the pan of care? (select all that apply A. monitor for bradycardia B. provide an emesis basin at the bedside C. administer antipyretic medication D. perform a skin assessment E. keep the head of the bed flat

answer: B, C, D

A nurse is admitting an older adult client who has suspected osteoporosis. which of the following is an expected finding (select al that apply) A. history of consuming one glass of wine day B. loss of height of 2 in C. body mass index of 21 D. kyphotic curve at upper thoracic spine E. history of lactose intolerance

answer: B, C, D, E

A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. the nurse should expect which of the following findings? (select all that apply) A. skin reddened over the joint B. pain when bearing weight C. joint crepitus D. swelling of the affected joint E. limited joint motion

answer: B, C, D, E

a nurse is educating clients at a heath fair about dual-energy x-ray absorptiometry (DXA) scans. which of the following information should the nurse include in the teaching (select all that apply) A. the test requires the use of contrast material B. the hip and spine are the usual arms th device snacks C. the scan detects ostoarthris D. bone pain can indicate a need for a scan E. at age 40 years, you should have a baseline scan

answer: B, D, A

a nurse is completing discharge teaching to a client who has seizures and received a vagal nerves stimulator to decrease seizure activity. which of the following statements should the nurse include in the teaching? A. it is safe to use microwave that are 1200 watts or less B. you should avoid the use of CT scans with contrast C. you should place a magnet over the implantable device when you feel an aura occurring D. it is recommended that you use ultrasound diathermy for pain management

answer: C

in which of the following positions should the nurse place a client following a craniotomy for evacuation of a subdural hematoma of the frontal lobe? A. supine B. Prone C. semi-fowlers D. sims

answer: C semi-fowlers -following a craniotomy, the client must be positioned with the head midline and the head of bed elevated 30 degrees. this positioning permits blood flow to the brian while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure

A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. which of the following information should the nurse include? A.consider taking oral contraceptives when on this medication B.watch for receding gums when taking this medication C.take the medication at the same time everyday D.provide a urine sample to determine therapeutic levels f the medication

answer: C take the medication at the same time everyday

a nurse is reviewing the use of the meningococcal vaccine for the prevention of meningitis with a newly licensed nurse. which of the following information should the nurse include? A. the vaccine is indicated to reduce the risk of respiratory infection B. the vaccine is administered in a series of four doses C. the vaccine is recommended for adolescents before starting college D. the vaccine is initially given at 2 months of agents

answer: C. the vaccine is recomenede for adolescents before starting college

a nurse is caring for a client who was admitted secondary to transient ischmei attacks (TIA). the goal of therapy for the client is: A. reversal of disability B. reduction of cerebral bleeding C. reduction of cerebral edema D. prevention of cerebrovascular accident

answer: D prevention of cerebrovascular accident -TIAs are considered a warning sign of advnacnced atherosclerotic diseease. common symptoms of TIA include loss of vision in one eye, inability to speak, transient hemiparesis, tinnitus, vertiog, diplopia, dysphagia, numbness, and weakness. once a diagnosis is made the client can receive medications that prevent platelet aggregation. the most common surgical procedure to reduce the frequency of TIAs and the danger of a cerebrovascular accident is a carotid endarterectomy. during this procedure, the carotid arteries are scraped to remove the plaque that has caused a reduction in the blood supply to the brain

A nurse is caring for a client who is postoperative following a craniotomy to evacuate a subdural hematoma. The nurse notes the clients urine output is greater each hour than the previous hour: from 8-9 the urine output was 200 mL, from 9-10 it was 400 mL, and from 10-11 it was 600 mL. the nurse informs the surgeon and anticipates that the lab values that will be prescribed at this time is: A. BUN B. Blood sugar C. urine ketones D. specific gravity

answer: D specific gravity -the nurse recognizes that the client has manifestation suggestive of DI. DI is casted by damage to the hypothalamus or the pituitary gland as a result of surgery, infection or a tumor rom cranial surgery. it is a condition in which an inadequate amount of aADH is released making the kidneys unable to conserve water, therefore causing extreme polyuria. a n extremely low specific gravity (1.00-1.003) is commonly seen with diabetes insidious and is the next most likely test to be prescribed

A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoproosis. which of the following foods should the nurse include in the instructions? A. white bread B. White beans C. white meat of chicken D. white rice

answer: b white beans

a nurse is caring for a client who has a closed had injury with ICp readings ranging from 16-22 mmHg.which of the following actions should the nurse take to decrease the potential for raising the clients ICP (select all that apply) A. suction the endotracheal tube frequently B. decrease the noise level in the clients room C. elevate the clients head on two pillow D. administer stool softener

answer: d