Stroke
A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect? severe pain, blisters, and blanching with pressure pain, minimal edema, and blanching with pressure redness, evidence of inhalation injury, and charred skin no pain, waxy white skin, and no blanching with pressure
no pain, waxy white skin, and no blanching with pressure
A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? cataracts open angle glaucoma macular degeneration angle closure glaucoma
open angle glaucoma
signs and symptoms of compartment syndrome include which of the following: SATA pain pallor pulsations pulselessness paresthesias
pain pallor pulselessness paresthesias
The nurse provides dietary instructions to the in-home caregiver of a 45-yr-old man with Huntington's disease. The nurse is most concerned if the caregiver makes which statement? "Depression is common and may cause a decrease in appetite." "If swallowing becomes difficult, a feeding tube may be needed." "Calories should be restricted to prevent unnecessary weight gain." "Muscles in the face are affected, and chewing may become impossible."
"Calories should be restricted to prevent unnecessary weight gain."
the nurse determines that the woman with the highest risk for osteoporosis is a: 60 year old aerobics instructor 65 year old on estrogen therapy 45 year old obese African American 44 year old Caucasian cigarette smoker
44 year old Caucasian cigarette smoker
The nurse provides information to the caregiver of a 68-yr-old man with epilepsy who has tonic-clonic seizures. Which statement by the caregiver indicates a need for further teaching? "It is normal for a person to be sleepy after a seizure." "I should call 911 if breathing stops during the seizure." "The jerking movements may last for 30 to 40 seconds." "Objects should not be placed in the mouth during a seizure."
"I should call 911 if breathing stops during the seizure."
When teaching a patient about the pathophysiology related to open-angle glaucoma, which statement is most appropriate? "The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." "The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye." "The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye."
"There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve."
The nurse is reinforcing teaching with a newly diagnosed patient with ALS. Which statement would be appropriate to include in the teaching? "ALS results from an excess chemical in the brain, and the symptoms can be controlled with medication" "Even though the symptoms you are experiencing are severe, most people recover with treatment" "You need to consider advance directives now, since you will lose cognitive function as the disease progresses" "This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function"
"This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function"
The nurse teaches a 38-yr-old woman who has migraine headaches about sumatriptan (Imitrex). Which statement by the patient requires clarification by the nurse? "The injection might feel like a bee sting." "This medicine will prevent a migraine headache." "I can take another dose if the first does not work." "This drug for migraine headaches could cause birth defects."
"This medicine will prevent a migraine headache."
The nurse is preparing to administer timolol eye drops for treatment of glaucoma. What statement made by the patient would cause the nurse to hold the medication and report to the health care provider? "i have sinusitis" "i have migraine headaches a lot" "i have chronic obstructive pulmonary disease" "I have a history of chronic urinary tract infections"
"i have chronic pulmonary disease" Timolol is a nonselective β-adrenergic blocker that could lead to bronchoconstriction and bronchospasm. For this reason, it should not be used in patients with COPD. Timolol may be used to treat migraine headaches, and it does not affect sinusitis or chronic urinary tract infections.
The nurse is teaching a patient about timolol eye drops for the treatment of glaucoma. What statement made by the patient demonstrates that teaching was effective? "i may feel some palpitations after instilling these drops" "i should withhold this medication if my blood pressure becomes elevated" "I should keep my eyes closed for 15 minutes after instilling these eye drops" "i may have some temporary blurring of vision after instilling these eye drops"
"i may have some temporary blurring of vision after instilling these eye drops"
The nurse instructs a patient prescribed dipivefrin eye drops to manage chronic open-angle glaucoma. Which statement, if made by the patient to the nurse, indicates that further teaching is needed? "the eye drops could cause a fast heart rate and high blood pressure" "i will need to take the eye drops twice for at least 2 to 3 months" "I may experience eye discomfort and redness from the use of these eye drops" "i will apply gentle pressure on the inside corner of my eye after each eye drop"
"i will apply gentle pressure on the inside corner of my eye after each eye drop"
The nurse is teaching a patient with glaucoma about administration of pilocarpine. What statement is important for the nurse to include during the instructions? "Prolonged eye irritation is an expected adverse effect of this medication" "this medication will help to raise intraocular pressure to a near normal level" "this medication needs to be continued for at least 5 years after your initial diagnosis" "it is important not to do activities requiring visual acuity immediately after administration"
"it is important not to do activities requiring visual acuity immediately after administration"
A patient informs the nurse that they are afraid to use the treatment recommended for psoriasis. What is the best response by the nurse? "you will only know if you try it and see" "you may need to get counseling to help you cope" "no treatment is medically necessary but it can be removed" "topical, light therapy, and systemic medications are now available"
"topical, light therapy, and systemic are now available"
A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching "You can resume playing golf in two days" "you need to tilt your head back when washing your hair" "you can get water in your eyes in 1 day" "you need to limit your housekeeping activities"
"you need to limit your housekeeping activities"
A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 18% 22.5% 27% 36%
22.5% Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore, adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.
Which patient should the nurse prepare to transfer to a regional burn center? A 25-yr-old pregnant patient with a carboxyhemoglobin level of 1.5% A 39-yr-old patient with a partial-thickness burn to the right upper arm A 53-yr-old patient with a chemical burn to the anterior chest and neck A 42-yr-old patient who is scheduled for skin grafting of a burn wound
A 53-yr-old patient with a chemical burn to the anterior chest and neck The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma. Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.
The nurse is teaching about skin cancer prevention at the community center. Which person is most at risk for developing skin cancer? A 67-yr-old bald-headed man with psoriasis and type 2 diabetes mellitus A 76-yr-old Hispanic man who has a latex allergy and numerous acrochordons A 55-yr-old woman with fair skin and red hair who has a family history of skin cancer A 62-yr-old woman with chronic kidney disease who has blond hair with dry, pale skin
A 55-yr-old woman with fair skin and red hair who has a family history of skin cancer
The nurse should recognize that which patient is likely to have the poorest prognosis? A patient who is being treated for stage IV malignant melanoma A patient diagnosed with nodular ulcerative basal cell carcinoma A patient who has been diagnosed with late squamous cell carcinoma A patient whose biopsy has revealed superficial squamous cell carcinoma
A patient who is being treated for stage IV malignant melanoma
A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply) A. Speak to the client at a slower rate B. Look directly at the client when speaking C. Allow extra time for the client to answer D. Complete sentences that the client cannot finish E. Give instructions one step at a time
A, B, C, E
A nurse is planning care for a client who has dysphagia and has 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. Use thickened liquids C. Place food on the client's unaffected side of her mouth D. Assign as assistive personnel to feed the client slowly E. Teach the client to swallow with her neck flexed
A, B, C, E
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 client's 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 client's wheelchair on her left side
B The client is unable to visualize to the left midline of her body. Placing the client's bedside table on the right side of her bed will permit visualization of items on the table
*A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception
C The inability to recognize familiar objects is called agnosia
When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what nursing action would be a priority? Recognizing that eye damage caused by glaucoma can be reversed in the early stages Giving anticipatory guidance about the eventual loss of central vision that will occur Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision Managing the pain experienced by patients with glaucoma that persists until the optic nerve atrophies
Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision
The patient with type 1 diabetes mellitus is having a seizure. Which medication should the nurse anticipate will be administered first? IV dextrose solution IV diazepam (Valium) IV phenytoin (Dilantin) Oral carbamazepine (Tegretol)
IV dextrose solution
The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient? subcut tetanus toxoid IV morphine sulfate IM hydromorphone Oral oxycodone and acetaminophen
IV hydromorphone
A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? The total 24-hour fluid requirement should be administered in the first 8 hours. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.
One half of the total 24-hour fluid requirement should be administered in the first 8 hours.
A 48-yr-old man was just diagnosed with Huntington's disease. His 20-yr-old son is upset about his father's diagnosis. What is the nurse's best response? Provide emotional and psychologic support. Encourage him to get diagnostic genetic testing. Explain that cognitive deterioration will be treated with counseling. Instruct that chorea and psychiatric disorders can be treated with haloperidol (Haldol).
Provide emotional and psychologic support.
A male patient with a diagnosis of Parkinson's disease (PD) is admitted to a long-term care facility. Which action should the health care team take to promote adequate nutrition for this patient? Provide multivitamins with each meal. Provide a diet that is low in complex carbohydrates and high in protein. Provide small, frequent meals throughout the day that are easy to chew and swallow. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.
Provide small, frequent meals throughout the day that are easy to chew and swallow.
Which characteristic will the nurse associate with a focal seizure? The patient lost consciousness during the seizure. The seizure involved both sides of the patient's brain. The seizure involved lip smacking and repetitive movements. The patient fell to the ground and became stiff for 20 seconds.
The seizure involved lip smacking and repetitive movements.
Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
b
Which care measure is a priority for a patient with multiple sclerosis (MS)? a. Vigilant infection control and adherence to standard precautions b. Careful monitoring of neurologic assessment and frequent reorientation c. Maintenance of a calorie count and hourly assessment of intake and output d. Assessment of BP and monitoring for signs of orthostatic hypotension
Vigilant infection control and adherence to standard precautions
A CT scan of a 68-yr-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? a. Maintenance of the patient's airway b. Positioning to promote cerebral perfusion c. Control of fluid and electrolyte imbalances d. Administration of tissue plasminogen activator (tPA)
a
A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.
a
A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.
a
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from inside an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery, and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."
a
After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled d. A 40-yr-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
a
The patient with diabetes mellitus had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient? a. safety measures b. patience with communication c. mobility assistance on the right side d. place food in the left side of patient's mouth
a
Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? a. hypertension b. hyperlipidemia c. alcohol consumption d. oral contraceptive use
a
Which patient has the highest risk of developing malignant melanoma? a fair skinned woman who uses a tanning bed regularly an african american patient with a family history of cancer an adult who required phototherapy as an infant for the treatment of hyperbilirubinemia a hispanic man with a history of psoriasis and eczema that responded poorly to treatment
a fair skinned woman who uses a tanning bed regularly
Pain management for the burn patient is most effective when SATA a pain rating tool is used to monitor the patient's level of pain painful dressing changes are delayed until the patient's pain is completely relieved the patinet is informed about and has some control over the management of pain a multimodal approach is used (sustained release and short acting opioids, NSAIDs, adjuvant anagesics) nonpharmacologic therapies
a pain rating tool is used to monitor the patient's level of pain the patient is informed about and has some control over the management of pain a multimodal approach is used (sustained release and short-acting opioids, NSAIDs, adjuvant anagesics)
The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply.)? a. ticlopidine b. clopidogrel c. enoxaparin d. dipyridamole e. enteric-coated aspirin f. tissue plasminogen activator
a, b, d, e
Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? absence of pain or pressure blurred vision in the morning seeing colored halos around light eye pain accompanied with nausea and vomiting
absence of pain or pressure
When teaching the patient in the rehabilitation phase of a severe burn about the use of range-of-motion (ROM), what explanations should the nurse give to the patient (select all that apply.)? the exercises are the only way to prevent contractures active and passive ROM maintain function of body parts ROM will show the patient that movement is still possible movement facilitates mobilization of fluid in interstitial spaces back into the vascular bed active and passive ROM can only be done while the dressings are being changed
active and passive ROM maintain function of body parts ROM will show the patient that movement is still possible movement facilitates mobilization of fluid in interstitial spaces back into the vascular bed Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.
The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse? administer 100% humidified oxygen teach the patient deep breathing exercises encourage the patient to express his feelings assist the patient to a high fowler's position
administer 100% humidified oxygen
A patient is admitted to the burn center with burns of his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields, On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? obtain vital signs and STAT arterial blood gas encourage the patient to cough and auscultate the lungs again document the findings and continue to monitor the patient's breathing anticipate the need for endotracheal intubation and notify the physician
anticipate the need for endotracheal intubation and notify the physician
A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is: applying pressure garments repositioning the patient every 2 hours performing ROM every 2 hours administer IV fluids as ordered
applying pressure garments
A patient with poor visual acuity is diagnosed with age-related macular degeneration (AMD). Which nursing action should be the nurse's priority? Teach about visual enhancement techniques teach nutritional strategies to improve vision assess coping strategies and support systems assess impact of vision on normal functioning
assess impact of vision on normal functioning
A patient with Ménière's disease had decompression of the endolymphatic sac to reduce the frequent and incapacitating attacks being experienced. What should the nurse include in the discharge teaching for this patient? airplane travel will be more comfortable now avoid sudden head movements or position changes cough or blow nose to keep the eustachian tubes clear take antihistamines, antiemetics, and sedatives for recovery
avoid sudden head movements or position changes
A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan.
b
A female patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? a. Position the patient on her weak side the majority of the time. b. Alternate the patient's positioning between supine and side-lying. c. Avoid the use of pillows in order to promote independence in positioning. d. Establish a schedule for the massage of areas where skin breakdown emerges.
b
A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. Which additional findings would the nurse expect? a. An aura or focal seizure b. Nystagmus or confusion c. Abdominal pain or cramping d. Irregular pulse or palpitations
b
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. tPA b. aspirin c. warfarin (Coumadin) d. nimodipine
b
For a patient who had a right hemisphere stroke, the nurse anticipates planning interventions to manage a. impaired physical mobility related to right-sided hemiplegia. b. risk for injury related to denial of deficits and impulsiveness. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.
b
For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal b. time at which stroke symptoms first appeared c. patient's hypertension history and management d. family history of stroke and other cardiovascular diseases
b
Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.
b
The most common response of the stroke patient to the change in body image is: a. denial b. depression c. disassociation d. intellectualization
b
The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.
b
The nurse observes a 74-yr-old man with Parkinson's disease rocking side to side while sitting in the chair. Which action by the nurse is most appropriate? a. provide the patient with diversional activities b. document the activity in the patient's health record c. Take the patient's blood pressure sitting and standing. d. Ask if the patient is feeling either anxious or depressed.
b
The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? a. impulsivity b. impaired speech c. left-side neglect d. short attention span
b
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c. that clopidogrel will dissolve clots in the cerebral arteries. d. that clopidogrel will reduce cerebral artery plaque formation.
b
What should be included in the nursing plan for a patient who needs to administer antibiotic eardrops? cool the drops so that they decrease swelling in the canal avoid placing a cotton wick to assist in administering the drops be careful to avoid touching the tip of the dropper bottle to the ear keep the head tilted to 5 to 7 minutes after administration of the drops
be careful to avoid touching the tip of the dropper bottle to the ear
When assessing a patient with a partial thickness burn, the nurse would expect to find which of the following? SATA blisters exposed fascia exposed muscles pain red, shiny, wet appearance
blisters pain red, shiny, wet appearance
when monitoring initial fluid replacement for the patient with 40% TBSA deep partial thickness and full thickness burns, which of the following findings is of most concern to the nurse? urine output of 35 ml/hr serum K+ of 4.5 mEq/L decreased bowel sounds blood pressure of 86/52
blood pressure of 86/52
The nurse is caring for a client who has a new diagnosis of cataracts. which of the following manifestations should the nurse expect? SATA eye pain floating spots blurred vision white pupils bilateral red reflexes
blurred vision white pupils
A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.
c
A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia
c
A patient admitted with possible stroke has been aphasic for 3 hours, and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Administer tissue plasminogen activator (tPA) intravenously per protocol.
c
A patient experiencing TIA's is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to: a. decrease cerebral edema b. reduce the brain damage that occurs during a stroke in evolution c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation
c
A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.
c
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.
c
A patient will attempt oral feedings for the first time after having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.
c
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (chest x-ray) c. Computed tomography (CT) scan d. 12-Lead electrocardiogram (ECG)
c
A patient with right sided hemiplegia and aphasia resulting from a stroke most likely has involvement in the a. brainstem b. vertebral artery c. left middle cerebral artery d. right middle cerebral artery
c
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).
c
Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake b. keeping a urinal in place at all times c. assisting the patient to stand to void d. catheterizing the patient every 4 hours
c
During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.
c
The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output b. oxygen content of the blood c. degree of collateral circulation d. level of carbon dioxide in the blood
c
The nurse explains to a stroke patient who is scheduled for an angiography that this test is used to determine the: a. presence of increased intracranial pressure b. site and size of the infarction c. patency of the blood vessels d. presence of blood in the cerebrospinal fluid
c
The nurse is planning psychosocial support for the family of the patient who suffered a stroke. What factor will have the greatest impact on family coping? a. specific patient neurologic deficits b. the patient's ability to communicate c. rehabilitation potential of the patient d. absence of complications of stroke
c
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve.
c
When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/LVN? a. Screen patient for tPA eligibility. b. Assess the patient's ability to swallow. c. Administer scheduled anticoagulant medications. d. Place equipment needed for seizure precautions in room.
c
Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? a. Overestimation of physical abilities b. Difficulty judging position and distance c. Slow and possibly fearful performance of tasks d. Impulsivity and impatience at performing tasks
c
Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 lb above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.
c
When establishing a diagnosis of multiple sclerosis (MS), which diagnostic tests will the nurse expect (select all that apply.)? a. EEG b. ECG c. CT scan d Carotid duplex scan e. evoked response testing f. cerebrospinal fluid analysis
c, e, f
During the emergent phase of a burn injury, the nurse assesses for the presence of hypovolemia. in burn patients, hypovolemia occurs primarily as a result of: blood loss from injured tissue third spacing of fluid into fluid filled vesicles evaporation of fluid from denuded body surfaces capillary permeability with fluid shift to the interstitial spaces
capillary permeability with fluid shift to the interstitial spaces
During treatment of the patient with an acute attack of gout, the nurse would expect to administer aspirin colchicine allopurinol probenecid
colchicine
A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? a. Assist the patient to the bathroom every 2 hours. b. Provide incontinence briefs to wear during the day. c. Administer a bisacodyl (Dulcolax) rectal suppository every day. d. Arrange for several servings per day of cooked fruits and vegetables.
d
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin drip administration. d. tissue plasminogen activator (tPA) infusion.
d
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure (BP) is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).
d
A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.
d
A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions
d
Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance b. a history of hypertension c. presence of motor weakness d. sudden onset of severe headache
d
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway
d
The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate? a. TIA b. embolic stroke c. thrombotic stroke d. subarachnoid hemorrhage
d
The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? a A 92-yr-old female patient who takes warfarin (Coumadin) for atrial fibrillation b A 28-yr-old male patient who uses marijuana after chemotherapy to control nausea c A 42-yr-old female patient who takes oral contraceptives and has migraine headaches d A 72-yr-old male patient who has HTN and DM and smokes tobacco
d
The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? a "Take the person to the hospital if a headache lasts for more than 24 hours." b "Stroke symptoms usually start when the person is awake and physically active." c "A person with a transient ischemic attack has mild symptoms that will go away." d "Call 911 immediately if a person develops slurred speech or difficulty speaking."
d
Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? a. Present several thoughts at once so that the patient can connect the ideas. b. Ask open-ended questions to provide the patient the opportunity to speak. c. Finish the patient's sentences to minimize frustration associated with slow speech. d. Use simple, short sentences accompanied by visual cues to enhance comprehension.
d
of the following patients, the nurse recognizes that the one with the highest risk of stroke is: a. an obese 45 year old native American b. a 35 year old Asian American woman who smokes c. a 32 year old white woman taking oral contraceptives d. a 65 year old african american with hypertension
d
In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? serum sodium and potassium increase serum sodium and potassium decrease edema and arterial blood gas improve diuresis occurs and hematocrit decreases
diuresis occurs and hematocrit decreases In the emergent phase, the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs so potassium levels decrease at the end of the emergent phase when fluid levels normalize.
To maintain a positive nitrogen balance in a major burn, the patient must eat a high-protein, low fat, high carbohydrate diet increase normal caloric intake by about three times eat at least 1500 calories/day in small, frequent meals eat rice and whole wheat for the chemical effect on nitrogen balance
eat a high-protein, low fat, high carbohydrate diet
The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change? morphine sertraline zolpidem enoxaparin
morphine
The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care (select all that apply.)? escharotomy administration of diuretics IV and oral pain medications daily cleansing and debridement application of topical antimicrobial agent
escharotomy IV and oral pain medications daily cleansing and debridement application of topical antimicrobial agent An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.
What should be included in the postoperative teaching of the patient who has undergone cataract surgery? SATA eye discomfort is often relieved with mild analgesics a decline in visual acuity is common for the first week stay on bedrest and limit activity for the first few days notify surgeon if an increase in redness or drainage occurs nighttime eye shielding and activity restrictions are essential to prevent eye strain
eye discomfort is often relieved with mild analgesics a decline in visual acuity is common for the first week
surgical treatment that is indicated for compartment syndrome is fasciotomy amputation internal fixation release of tendons
fasciotomy
When administering eye drops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? apply pressure to each eyeball for a few seconds after administration have the patient close the eyes and move them back and forth several times have the patient put pressure on the inner canthus of the eye after administration have the patient try to blink out excess medication immediately after administration
have the patient put pressure on the inner canthus of the eye after administration
The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? full liquids only whatever the patient requests high protein and low sodium foods high calorie and high protein foods
high calorie and high protein foods
When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? mannitol 75g IV urine for myoglobin lactated ringer's solution at 25 ml/hr sodium bicarbonate 24 mEq every 4 hours
lactated ringer's solution at 25 ml/hr
The nurse finds the patient in bed having a tonic-clonic seizure. the nurse should take the following actions SATA loosen restrictive clothing turn the patient to his/her side protect the patient's head from injury place a padded tongue blad between the patient's mouth restrain the patient's extremities to prevent soft tissue damage and bone injury
loosen restrictive clothing turn the patient to his/her side protect the patient's head from injury
When administering a scheduled dose of pilocarpine, in which area should the nurse place the drops? inner canthus outer canthus center of the eyeball lower conjunctival sac
lower conjunctival sac
A female patient complains of a throbbing headache. The nurse learns the patient has experienced photophobia and headaches previously. Which diagnosis does the nurse suspect? cluster headache migraine headache polycythemia vera hemorrhagic stroke
migraine headache
The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the acute to the emergent phase? begin IV fluid replacement monitor for signs of complications assess and manage pain and anxiety discuss possible reconstructive surgery
monitor for signs of complications Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.
During assessment of the patient diagnosed with fibromyalgia, the nurse would expect the patinet to report generalized muscle twitching and spasms pain and poor sleep with resulting fatigue profound and progressive muscle weakness that limits ADLs widespread musculoskeletal pain that is accompanied by fever and inflammation
pain and poor sleep with resulting fatigue
a patient with a fractured right hip has an open reduction and internal fixation of the fracture. post-op, the nurse plans to get the patient up to the chair only after the first post-op day keep the patient on bedrest until x-rays demonstrate healing keep leg abductor splints on the patient except while bathing position the patient only on the back and unoperative side while in bed
position the patient only on the back and unoperative side while in bed
A patient with MS has a nursing diagnosis of self care deficit R/T muscle spasticity and neuromuscular deficits. in providing care for the patient, it is most important for the nurse to teach family members how to care for the patient's needs encourage the patient to maintain social interactions to prevent social isolation promote the use of assistive devices so the patient can participate in self care activities perform all ADLs for the patient to conserve his/her energy
promote the use of assistive devices so the patient can participate in self care activities
A 65 year old woman was just diagnosed with Parkinson's disease. the priority nursing intervention is searching the internet for educational videos evaluating the home for environmental safety promoting physical exercise and a well balanced diet designing an exercise program to strengthen and stretch specific muscles
promoting physical exercise and a well balanced diet
During the assessment of a patient, you note an area of red, sharply defined plaques covered with silvery scales that are mildly itchy on the patient's knees and elbows. You recognize this finding as lentigo psoriasis actinic keratosis seborrheic keratosis
psoriasis
A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to reapply a new dressing without disturbing the wound bed observe the wound for signs of infection during dressing changes apply cool compresses for pain relief in between dressing changes wash the wound aggressively with soap and water three times a day
reapply a new dressing without disturbing the wound bed
The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? blisters reddening of the skin destruction of all skin layers damage to sebaceous glands
reddening of the skin The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.
A 50-yr-old male patient has been diagnosed with amyotrophic lateral sclerosis (ALS). What strategy will prevent a common cause of death for patients with ALS? reduce fat intake reduce the risk of aspiration decrease injury related to falls decrease pain secondary to muscle weakness
reduce the risk of aspiration
A patient is recovering from second and third-degree burns over 30% of his body and is now ready for discharge. The first action the nurse should take when meeting with the patient would be to arrange a return-to-clinic appointment and prescription for pain medications teach the patient and the caregiver proper wound care to be performed at home review the patient's current health care status and readiness for discharge to home give the patient written discharge information and webistes for additional information for burn survivors
review the patient's current health care status and readiness for discharge to home
Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include adherence of albumin to vascular walls movement of potassium into the vascular space sequestering of sodium and water in interstitial fluid hemolysis of red blood cells from large volumes of rapidly administered fluid
sequestering of sodium and water in interstitial fluid
A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury (select all that apply.)? singed nasal hair generalized pallor painful swallowing burns on the upper extremities history of being burned in an enclosed space
singed nasal hair generalized pallor painful swallowing history of being burned in an enclosed space
The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? skin is hard with a dry, waxy white appearance skin is shiny and red with clear, fluid filled blisters skin is red and blanches when slight pressure is applied skin is leathery with visible muscles, tendons, and bones
skin is shiny and red with clear, fluid filled blisters Deep partial-thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial-thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.
When teaching a patient with a seizure disorder about the medication regimen, it is most important for the nurse to stress that the patient should increase the dose if stress is increased if gingival hyperplasia occurs the drug should be stopped and the physician notified stopping the medication abruptly may increase the intensity and frequency of the seizures most over the counter and prescription drugs are safe to take with anticonvulsant drugs
stopping the medication abruptly may increase the intensity and frequency of the seizures
The injury that is least likely to result in a full-thickness burn is sunburn scald injury chemical burn electrical injury
sunburn
A patient with a burn inhalation injury is receiving albuterol for the treatment of bronchospasm. What is the most important adverse effect of this medication for the nurse to monitor? tachycardia restlessness hypokalemia GI distress
tachycardia Albuterol stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a noncardioselective agent so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol.
A patient admitted with heart failure is also diagnosed with herpes zoster and draining vesicles. Which action, if observed by the nurse, would require additional teaching for that individual? The dietitian wears a mask when entering the patient's room the patient keeps the draining vesicles covered with a dressing the student nurse who takes prednisone requests a different patient assignment the nursing assistant washes hands frequently and wears gloves when in the room
the dietitian wears a mask when entering the patient's room
In teaching a patient with malignant melanoma about this disorder, the nurse recognizes that the patient's prognosis is most dependent on the thickness of the lesion the degree of asymmetry in the lesion the amount of ulceration in the lesion how much of the lesion has spread superficially
the thickness of the lesion
The nurse finds a patient in bed having a generalized tonic-clonic seizure. What is the best action by the nurse? restrain the patient to prevent injury insert an oral airway into the patient's mouth suction the patient and administer oxygen turn the patient to the side
turn the patient to the side
A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected finding? presence of a purulent lesion in the external ear canal feeling of pressure in the ear bulging, red bilateral tympanic membranes unilateral hearing loss
unilateral hearing loss
The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation (select all that apply.)? urine output is 46 ml/hr heart rate is 94 bpm urine specific gravity is 1.040 mean arterial pressure is 54 systolic blood pressure is 88
urine output is 46 ml/hr heart rate is 94 bpm Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats/min. Normal range for urine specific gravity is 1.003 to 1.030.
A newly diagnosed patient with MS has been hospitalized for evaluation and initial treatment of the disease. Following discharge teaching, the nurse realizes that additional instruction is needed when the patient says it is important for me to avoid exposure to people with upper respiratory infections when i begin to feel better, i should stop taking the prednisone to prevent the side effects i plan to use vitamin supplements and a high protein diet to help manage my condition i must plan with my family how we are going to manage my care if i become incapacitated
when i begin to feel better, i should stop taking the prednisone to prevent the side effects
