Term 4 Exam#1 Review
Because bowel contents from an ilestomy are virtually liquid, what should the nurse include in the plan of care?
evaluation and assessment of peristomal skin integrity
The nurse is caring for a home health patient who had a spinal cord injury at C5 three years ago. The nurse bases the plan of care on the knowledge that the patient will be able to
feed self with setup and adaptive equipment
Bowel sound assessment on a patient with an obstruction who has distention, nausea, and visible peristaltic waves would be:
high pitched
what is the most common procedure for the removal of the gallbladder?
laparoscopic cholecystomy
a therapeutic measure to reduce increased intracranial pressure is
limit fluid intake
what are the effects of normal aging on the nervous system? select all that apply
loss of neurons, reduction of cerebral blood flow, lipofuscin, decrease in oxygen use,
The patient, injured in an automobile accident, is being evaluated in the emergency department for a possible head injury. Which test should not be done if there is an indication of increased intracranial pressure?
lumbar puncture
Following a myelogram the nurse should include in the postprocedure care assessment for:
sensation in lower extremities
What is the nurse assessing when asking the patient, "Who is the president of the United States?" during a level of consciousness assessment?
Fund of knowledge
A patient has a head injury and is presenting with signs and symptoms of increased intracranial pressure. Which nursing intervention would be helpful in reducing this pressure?
Place the neck in a neutral position (not flexed or extended) to promote venous drainage.
A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which findings noted in the client history indicates that the client may be ineligible for this diagnostic procedure
Prosthetic valve replacement
A frantic family member is distressed about the flaccid paralysis of her son following a spinal cord injury several hours ago. What does the nurse know about this condition?
It is possibly a temporary condition and will clear
A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with respect to this diagnostic test?
Obtain an allergy history before the test
A client is being scheduled for a positron emission tomography (PET) scan of the brain. The nurse should provide which explanation to the client?
"The test detects abnormal glucose metabolism in the brain."
The physician orders metoprolol 25 mg orally twice a day for a patient with hypertension. Metoprolol is available in 50 mg tablets. How many tablets will the nurse administer?
0.5 tablet
The physician orders Cipro 750mg po twice a day for sinusitis. The medication is supplied in 500mg tablets. How many tablets will the nurse administer?
1.5 tablets
The physician orders ascorbic acid 600mg oral daily for a patient with anemia. Ascorbic acid is available in 300mg tablets. How many tablets will the nurse administer?
2 tablets
The physician orders magnesium oxide 400 mg oral three times a day for a patient with hypomagenseia. Magnesium oxide is available in 200 mg tablets. How many tablets would the nurse administer with each dose?
2 tablets
The physician orders potassium chloride crystals CR 40mEq twice a day orally for a patient with hypokalemia. Potassium chloride crystals CR are available in 20 mEq tablets. How many tablets would the nurse administer with each dose?
2 tablets
The nurse is aware that when assessing a patient by the four score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response and respiration. How are these results reported?
As individual score in each category
A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record?
"Exhibits a positive Babinski sign"
The nurse is preparing a client who is scheduled to undergo cerebral angiography. The nurse should assess the client for which finding?
Allergy to iodine or shellfish
A client with expressive aphasia becomes agitated and upset when attempting to communicate with the nurse. To help reduce the client's frustration the nurse should
Allow the patient adequate time to speak
A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding?
Accomodation
Why are peptic ulcers a common problem of aging?
Because of overuse of NSAIDS
What does the nurse know about the stroke patient who has expressive aphasia?
Can understand the spoken word, but cannot speak
Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem?
Can you describe the sensations you are having
A lumbar puncture is performed to obtain which specimen?
Cerebral Spinal Fluid
What is the cardinal sign of increased intracranial pressure in a brain injured patient?
Decrease in the level of consciousness
what are the two divisions of the nervous system
central nervous system and peripheral nervous system
A client arrives on the nursing unit unconscious and exhibiting decerebrate posturing. When assessing the client, the nurse expects to observe:
Hyperextension of both the upper and lower extremities
The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?
Increasing temperature, decreasing pulse, decreasing respirations, increasing BP
A client is found unconscious and unresponsive. What should the nurse do first?
Initiate a code.
A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure?
Maintaining the client in the supine position for several hours
When caring for a jaundiced patient with cirrhosis, what should the nurse include provisions for in the plan of care?
Skin care to prevent pruritus
When teaching about aging, the nurse explains that older adults usually have what characteristic?
Slower reaction times
A nurse is precepting an oriented (newly hired nurse). The nurse observes the oriented caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the oriented performs?
Suctioning the oropharynx routinely
the nurse is caring for a client who is scheduled to have electroencephalography. the nurse determines that the client is ready for the procedure after which of the following
The client has not had breakfast
Which symptom is specific to migraine headaches?
They are preceded by an aura
The client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats per minute range. The client is also complaining of nausea. The nurse interprets that these symptoms are because of stimulation of which cranial nerve?
Vagus
The nurse anticipates that the patient who has had a subtotal gastrectomy will need supplemental:
Vitamin b12 due to the loss intrinsic factor
A client with a head injury is admitted to the hospital. Which client response indicates increasing intracranial pressure?
Widening pulse pressure
why is it advantageous for a live person to be a liver donor
because the donor only donates part of the liver
When planning care for a patient with aphasia, the nurse should
consider the type of aphasia that the patient has and adapt communication methods accordingly
A patient, age 52, is brought to the emergency department by ambulance after she hit her head on her bathroom sink and fell unconscious to the floor. Which assessment should the nurse perform first?
patency of airway
What is the most lethal complication of PUD?
perforation
What is the basic problem that prompts most of the early signs of Alzheimer's disease
memory loss that disrupts daily life
The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment?
Gently wipe nose with absorbent gauze
A patient has recently suffered a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely?
Tuck chin when swallowing
Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.)
Yogurt caffeine Marinated foods
A nurse is preparing to administer a prescribed antibiotic to a client with bacterial meningitis. The nurse understands that the selection of an antibiotic to treat meningitis is based on which fact?
It is able to cross the blood-brain barrier
