556 Quizzes 1-3
Which of the following symptoms do you as the nurse expect to see in the patient with primary progressive multiple sclerosis? (Select All that Apply): A. Blurred double vision B. Fatigue C. Diarrhea D. Intention tremors E. Paralytic ileus
Answer Key: A, B, 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. Hyperactive left-sided tendon reflexes B. Right-sided neglect C. Impulsive behavior D. Difficulty comprehending instructions
Answer Key: D
Which signs or symptoms should the nurse report immediately because they indicate thrombocytopenia secondary to cancer chemotherapy? Select all that apply. A. Fever B. Bruises C. Petechiae D. Pallor E. Epistaxis
Answer Key: B Feedback: Fever is a sign of infection secondary to neutropenia.Pallor is a sign of anemia.
Smoking may significantly increase the risk of secondary malignancies True False
Answer Key: True
The RN is caring for a PT with increased ICP. Which nursing action should be avoided? A. Reposition the patient every two hours. B. Position the patient with the head elevated 30 degrees. C. Suction the airway every two hours per standing orders. D. Provide continuous oxygen as ordered.
Answer Key: C
What is a hallmark feature of Hodgkin's lymphoma A. Downey cells B. Increased number of B cells C. Reed-Sternbery cells from lymph node biopsy D. Chronic cough
Answer Key: C
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? A. Yellow-tinged sclerae B. Numbness of the extremities C. Gum bleeding and tenderness D. Shiny, smooth tongue
Answer Key: B
What components of the lab results suggest acute leukemia? A. A positive troponin lab B. increased AST, LDL levels C. Multiple myeloblasts specific to AML, WBC count, platelet count, low hematocrit, low hemoglobin D. Elevated BNP, CKMB
Answer Key: C
The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? A. Check temperature every 4 hours. B. Avoid intramuscular injections. C. Encourage increased oral fluids. D. Increase intake of iron-rich foods.
Answer Key: B
Which are the following are example of possible skin reactions that occur after Chemotherapy? A. Dry Desquamation B. Wet Desquamation C. Acne Vulgaris D. Contact Dermatitis
Answer Key: A, B
Which diagnostic test is used to confirm ALS? A. Electromyelogram (EMG) B. Muscle biopsy C. Serum creatinine D. Pulmonary function test
Answer Key: B
When the nurse is counseling a 60-year-old African-American male client with all of these risk factors for lung cancer, teaching should focus most on which risk factor? A. Gender B. Increased age C. Ethnicity D. Tobacco use
Answer Key: D Feedback: Although all of these are risk factors for lung cancer, the client's tobacco use is the only factor that he can change.
The nurse will assess a 67-year-old patient who is experiencing a cluster headache for A. nuchal rigidity. B. unilateral ptosis. C. projectile vomiting. D. throbbing, bilateral facial pain.
Answer Key: B Feedback: Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.
The nurse cares for the client being evaluated for Guillain-Barre Syndrome. Which sign is most suggestive of Guillain-Barre Syndrome? A. Ascending paralysis B. Numbness and tingling of the fingers C. Hyperactive reflexes D. Tinnitus
Answer Key: A
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? A. The patient is difficult to arouse. B. There are large bruises on the patient's back. C. There are purpura on the oral mucosa. D. The platelet count is 52,000/µL.
Answer Key: A
Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea? A. Ondansetron (Zofran) B. Diazepam (Valium) C. Morphine D. Naloxone (Narcan)
Answer Key: A Feedback: Ondansetron is a 5-HT3 receptor blocker that blocks serotonin to prevent nausea and vomiting. Diazepam is a benzodiazepine, which is an antianxiety medication only. Lorazepam, a benzodiazepine, may be used for nausea. What is Narcan used for?
Which statement made by the client allows the nurse to recognize whether the client who is receiving brachytherapy for ovarian cancer understands the treatment plan? A. "I will have a radioactive device in my body for a short time." B. "I must be positioned in the same way during each treatment." C. "I will be placed in a semiprivate room for company." D. "I may lose my hair during this treatment."
Answer Key: A Feedback: Brachytherapy refers to short-term insertion of a radiation source.
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/microliter. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? A. "The patient has developed acquired immunodeficiency syndrome (AIDS)." B. "The patient will develop symptomatic HIV infection within 1 year." C. "The patient meets the criteria for a diagnosis of acute HIV infection." D. "The patient will be diagnosed with asymptomatic chronic HIV infection."
Answer Key: A Feedback: Development of PCP meets the diagnostic criteria for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection.
The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient about A. triggers leading to facial discomfort. B. weakness on the affected side of the face. C. visual problems caused by ptosis. D. poor appetite caused by loss of taste.
Answer Key: A Feedback: The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? A. "Malignant tumors may spread to other tissues or organs." B. "Benign tumors are likely to recur in the same location." C. "Benign tumors do not cause damage to other tissues." D. "Malignant cells do not cause damage to other tissues than normal cells."
Answer Key: A Feedback: The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Benign tumors do not usually recur.
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about A. oral low-dose aspirin therapy. B. heparin intravenous infusion. C. cerebral aneurysm clipping. D. tissue plasminogen activator (tPA).
Answer Key: A Feedback: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
Your patient is scheduled for a lumbar puncture to help diagnose multiple sclerosis. The patient wants clarification about what will be found in the cerebrospinal fluid during the lumbar puncture to confirm the diagnosis of MS. You explain that ____________ may be present in the fluid if MS is present. A. increase in IgG B. high amounts of RBC C. low amounts of WBC D. oblong red blood cells and glucose
Answer Key: A Feedback: Your patient is scheduled for a lumbar puncture to help diagnose multiple sclerosis. The patient wants clarification about what will be found in the cerebrospinal fluid during the lumbar puncture to confirm the diagnosis of MS. You explain that ____________ may be present in the fluid if MS is present.
Priority nursing actions when caring for a hospitalized patient with a new onset temperature of 102.2 degrees F (39 degrees C) and severe neutropenia include (select all that apply) A. administering the prescribed antibiotic STAT. B. taking a full set of vital signs and notifying the physician immediately. C. drawing peripheral and central line blood cultures. D. administering transfusions of WBCs treated to decrease immunogenicity. E. ongoing monitoring of the patient's vital signs for septic shock.
Answer Key: A, B, C, E Feedback: See Evolve for Rationale
The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered? A. White blood cell count B. Platelet count C. Hemoglobin level D. Neutrophil count
Answer Key: C Feedback: Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.
A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? A. Side-rail pads B. Tongue blade C. Oxygen mask D. Suction tubing E. Urinary catheter F. Nasogastric tube
Answer Key: A, C, D Feedback: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.
The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)? A. Sunscreen use B. Tobacco use C. Pap testing D. Colorectal screening E. Mammography
Answer Key: A, C, D, E Feedback: The patient's age, gender, and history indicate a need for screening and/or teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.
During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply) A. inspect all aspects of the mouth and teeth. B. assess the gag reflex and respiratory rate and depth. C. lightly palpate the affected side of the face for edema. D. test for temperature and sensation perception on the face. E. ask the patient to describe factors that initiate an episode.
Answer Key: A, D, E
The nurse has received in report that the client receiving chemotherapy has severe neutropenia. Which of the following does the nurse plan to implement? Select all that apply. A. Assess for fever. B. Do not allow his 16-year-old son to visit. C. Observe for bleeding. D. Do not permit fresh flowers or plants in the room. E. Teach the client to omit raw fruits and vegetables from his diet.
Answer Key: A, D, E Feedback: Any temperature elevation in a client with neutropenia is considered a sign of infection and should be reported immediately. All fruits and vegetables should be cooked well; raw fruits and vegetables may harbor organisms, as well as Flowers and plants. Thrombocytopenia cause bleeding, not low neutrophils.The client is at risk for infection, not the visitors, if they are well. However, very small children, who may get frequent colds and viral infections, may pose a risk.
The nurse includes which of the following in teaching regarding the warning signs of cancer? Select all that apply. A. Scab present for 6 months B. Curdlike vaginal discharge C. Headache D. Axillary swelling E. Persistent constipation
Answer Key: A, D, E Rationale: axillary swelling could be due to swollen lymph, constipation could be colorectal Feedback: Change in bowel habit, A sore that does not heal, A lump or thickening in the breast or elsewhere is a warning signal of cancer.
A 38 year old woman has newly diagnosed Multiple Sclerosis (MS) and asks the nurse what is going to happen to her. The best response by the nurse is: A. " You need to plan for continuous loss of movement, sensory functions and mental capabilities" B. " Most people with MS have periods of attacks and remission, with progressively more nerve damage over time" C. " You will most likely have a steady course of chronic progressive nerve damage that will change your personality" D. " It is common for people with MS to have an acute attack of weakness and then a reversal of MS."
Answer Key: B
Myasthenia gravis occurs when antibodies attack the __________ receptors at the neuromuscular junction leading to ____________. A. metabotropic; muscle weakness B. nicotinic acetylcholine; muscle weakness C. dopaminergic adrenergic; muscle contraction D. nicotinic adrenergic; muscle contraction
Answer Key: B
The nurse is teaching a group of clients about cancers related to tobacco or tobacco smoke. Identify the common cancers related to tobacco use. Select all that apply. A. Cardiac cancer B. Lung cancer C. Cancer of the tongue D. Skin cancer E. Cancer of the larynx
Answer Key: B
The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock? A. Hyperactive reflexes below the injury B. Hypotension and warm extremities C. Lack of sensation or movement below the injury D. Involuntary and spastic movement
Answer Key: B Feedback: Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.
A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should A. explain to the family that depression is normal following a stroke. B. teach the family that emotional outbursts are common after strokes. C. use a calm voice to ask the patient to stop the crying behavior. D. have the family members leave the patient alone for a few minutes.
Answer Key: B Feedback: Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control, and asking the patient to stop will lead to embarrassment.
The client receiving chemotherapy will experience the lowest level of bone marrow activity and neutropenia during which period? A. Peak B. Nadir C. Trough D. Adjuvant
Answer Key: B Feedback: The lowest point of bone marrow function is referred to as the nadir. The peak of bone marrow function occurs when the client's blood levels are at their highest.Trough, which means low, is typically used in reference to drug levels.
A 72-year-old client recovering from lung cancer surgery asks the nurse to explain how she developed cancer when she has never smoked. Which factor may explain the possible cause? A. A diagnosis of diabetes treated with insulin and diet B. An exercise regimen of jogging 3 miles 4x/wk C. A history of cardiac disease D. Advancing age
Answer Key: D Feedback: Advancing age is the single most important risk factor for cancer. As a person ages, immune protection decreases.
A patient you are caring for has just been told that he has ALS. You know that he has a sedentary lifestyle, was a cigarette smoker for 10 years, and has a high stress job. He asks you what he could have done to prevent this disease. Your best response is: A. Smoking and an inactive lifestyle greatly contribute to the disease ALS. B. There is nothing that you could have done to prevent the ALS disease. C. Consistent high stress has been linked to the ALS diagnosis. D. Because your grandfather had ALS, you were likely to get it too.
Answer Key: B Feedback: the most common cause of ALS remains unknown and is currently under study. There is not currently any one known predictor or cause of disease
During your discharge teaching to a patient with multiple sclerosis, you educate the patient on how to avoid increasing symptoms and relapses. You tell the patient to avoid (select all that apply): A. Rest B. Infection C. Overexertion D. High caffeine intake
Answer Key: B, C, D
What is the treatment for Acute Myelogenous Leukemia (AML)? Select all that apply: A. Dialysis B. Chemotherapy C. Stem cell transplant D. Radiation E. Cricothyrotomy
Answer Key: B, C, D
A 30 year old patient is admitted with a diagnosis of myasthenia gravis and worsening of symptoms. In taking a history, which of the following complaints would the nurse consider most typical? A. stooped posture, dysphagia, tremor B. numbness, dysphagia, spasticity C. fading voice, dysphagia, exercise intolerance D. Spasticity, incontinence of bladder, auditory problems
Answer Key: C
A 65-yr-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is A. searching the Internet for educational videos. B. evaluating the home for environmental safety. C. promoting physical exercise and a well-balanced diet. D. designing an exercise program to strengthen and stretch specific muscles.
Answer Key: C
A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which initial response by the nurse is best? Incorrect A. Reflex erections frequently occur, but orgasm may not be possible. B. Sildenafil (Viagra) is used by many patients with spinal cord injury. C. Multiple options are available to maintain sexuality after spinal cord injury. D. Penile injection, prostheses, or vacuum suction devices are possible options.
Answer Key: C
The client with experiencing status epilepticus is admitted to the intensive care unit Which collaborative intervention should the nurse anticipate? A. Assess the client's neurological status every hour. B. Monitor the client's heart rhythm via telemetry. C. Administer an anticonvulsant medication by IV. D. Prepare to administer a glucocorticosteroid orally.
Answer Key: C
The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? A. "I can take the (Topamax) as soon as a headache starts." B. A glass of wine might help me relax and prevent a headache." C. "I will lie down someplace dark and quiet when the headaches begin." D. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."
Answer Key: C
The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? A. Walking on the toes B. Unsteady and staggering C. Shuffling and propulsive D. Broad-based and waddling
Answer Key: C
When caring for a client diagnosed with Guillain-Barre syndrome, which does the nurse identify as the MOST serious complication of this syndrome? A. Urinary retention B. Immobility C. Respiratory failure D. Loss of communication
Answer Key: C
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? A. Insert an oral airway during the seizure to maintain a patent airway. B. Restrain the patient's arms and legs to prevent injury during the seizure. C. Consider time and observe and record the details of the seizure and postictal state. D. Avoid touching the patient to prevent further nervous system stimulation.
Answer Key: C
To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level ? A. Support selection of a high-protein diet. B. Discuss options for sexuality and fertility. C. Assist in planning a prescribed bowel program. D. Use quad coughing to strengthen cough efforts.
Answer Key: C Feedback: Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? A. Hemoglobin of 13.8 g/dL B. Decreased white blood cell (WBC) count C. Elevated reticulocyte count D. Hematocrit of 46%
Answer Key: C Feedback: Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.
A male client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer? A. Rash B. Chronic ache or pain C. Indigestion D. Persistent nausea
Answer Key: C Feedback: Indigestion, or difficulty swallowing, is one of the seven warning signs of cancer. The other six are a change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, a thickening or lump in the breast or elsewhere, an obvious change in a wart or mole, and a nagging cough or hoarseness. Persistent nausea may signal stomach cancer but isn't one of the seven major warning signs. Rash and chronic ache or pain seldom indicate cancer.
Which intervention should the nurse take with the client recently diagnosed with ALS? A. Discuss a percutaneous gastrostomy tube. B. Explain how a fistula is accessed. C. Provide an advance directive. D. Refer to a PT for leg braces.
Answer Key: C Feedback: It is never too early to discuss advance directives with a client diagnosed with a terminal illness
Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which of the following dietary modifications should the nurse recommend? A. A diet emphasizing whole and organic foods B. A high-protein, high-calorie diet C. A bland, low-fiber diet D. A diet high in fresh fruits and vegetables
Answer Key: C Feedback: Patients experiencing diarrhea secondary to chemotherapy and/or radiation therapy often benefit from a diet low in seasonings and roughage. Fresh fruits and vegetables are high in fiber and should be minimized during treatment. Whole and organic foods do not prevent diarrhea.
The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first? A. A 42-yr-old patient with multiple sclerosis who was admitted with sepsis. B. A 72-yr-old patient with Parkinson's disease who has aspiration pneumonia C. A 38-yr-old patient with myasthenia gravis who declined prescribed medications D. A 45-yr-old patient with amyotrophic lateral sclerosis who refuses enteral feedings
Answer Key: C Feedback: Patients with myasthenia gravis who discontinue pyridostigmine (Mestinon) will experience myasthenic crisis. Myasthenia crisis results in severe muscle weakness and can lead to a respiratory arrest.
Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? A. Hematocrit 55% B. Presence of plethora C. Calf swelling and pain D. Platelet count 450,000/mL
Answer Key: C Feedback: The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.
Which of these does the nurse recognize as the goal of palliative surgery for the client with cancer? A. Cure of the cancer B. Prolonging the client's survival time C. Relief of symptoms or improved quality of life D. Allowing other therapies to be more effective
Answer Key: C Feedback: The focus of palliative surgery is to improve quality of life during the survival time.
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem? A. Tell the patient to limit social contacts until regrowth of the hair occurs. B. Teach the patient to gently wash hair with a mild shampoo to minimize hair loss. C. Encourage the patient to purchase a wig or hat and wear it once hair loss begins. D. Inform the patient that hair usually grows back once the chemotherapy is complete.
Answer Key: C Feedback: The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicle and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem
Which nursing diagnosis is a priority in the care of a patient with myasthenia gravis (MG)? A. Acute confusion B. Bowel incontinence C. Activity intolerance D. Disturbed sleep pattern
Answer Key: C Feedback: The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG. Although sleep disturbance is likely, activity intolerance is of primary concern.
The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect? A. Cool extremities B. Pallor and weakness . C. Elevated temperature D. Low oxygen saturation
Answer Key: C Feedback: The term "shift to the left" indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities.
A 35 years old client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)? A. Rust-colored sputum B. White, cottage cheese-like patches on the tongue C. Red, open sores on the oral mucosa D. Yellow tooth discoloration
Answer Key: C Feedback: The tissue-destructive effects of cancer chemotherapy typically cause stomatitis, resulting in ulcers on the oral mucosa that appear as red, open sores. White, cottage cheese-like patches on the tongue suggest a candidal infection, another common adverse effect of chemotherapy. Yellow tooth discoloration may result from antibiotic therapy, not cancer chemotherapy. Rust-colored sputum suggests a respiratory disorder, such as pneumonia.
A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient. A. A, B, C, D. B. B, C, A, D. C. D, C, A, B. D. C, D, A, B.
Answer Key: D
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. 12-Lead electrocardiogram (ECG) B. Chest radiograph (chest x-ray) C. Complete blood count (CBC) D. Computed tomography (CT) scan
Answer Key: D
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? A. "I can sit down to put on my pants and shoes." B. "I try to exercise every day and rest when I'm tired." C. "My son removed all loose rugs from my bedroom." D. "I don't need to use my walker to get to the bathroom."
Answer Key: D
The nurse will explain to the patient who has a T2 spinal cord transection injury that A. tachycardia is common with this type of injury. B. use of the shoulders will be limited. C. total loss of respiratory function may occur. D. function of both arms should be retained.
Answer Key: D
Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? A. An exaggerated startle reflex and memory changes. B. Cogwheel rigidity and inability to initiate voluntary movement. C. Sudden severe unilateral facial pain and inability to chew. D. Progressive ascending paralysis of the lower extremities and numbness.
Answer Key: D
Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? A. Application of pneumatic compression devices to legs B. Cardiac monitoring for bradycardia C. Administration of low-molecular-weight heparin D. Assessment of respiratory rate and effort
Answer Key: D Feedback: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate for preventing deterioration or complications but are not as important as assessment of respiratory effort.
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 works at a desk and relaxes by watching television. B. The patient is 25 lb above the ideal weight. C. The patient drinks a glass of red wine with dinner daily. D. The patient's usual blood pressure (BP) is 170/94 mm Hg.
Answer Key: D Feedback: Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase their risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate? A. "Do you think that taking an antidepressant might be helpful?" B. "It is important to focus on the good things about your life now." C. "Thinking about dying will not improve the course of AIDS." D. "Can you tell me more about the thoughts that you are having?"
Answer Key: D Feedback: More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" or suggesting an antidepressant discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient.
The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? A. A client with xerostomia associated with laryngeal cancer who needs oral care before breakfast B. A client with lymphoma who will need administration of an antiemetic before receiving chemotherapy C. A client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D. A client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature
Answer Key: D Feedback: Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune suppressed people; the nurse should see this client first.
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? A. Infuse the medication over a short period of time. B. Hold the medication unless a central venous line is available. C. Administer the chemotherapy through a small-bore catheter. D. Stop the infusion if swelling is observed at the site.
Answer Key: D Feedback: Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapeutic drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred.
The nurse is reinforcing teaching with a newly diagnosed patient with amyotrophic lateral sclerosis. Which statement would be appropriate to include in the teaching? A. "ALS results from an excess chemical in the brain, and the symptoms can be controlled with medication." B. "Even though the symptoms you are experiencing are severe, most people recover with treatment." C. "You need to consider advance directives now, since you will lose cognitive function as the disease progresses." D. "This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function."
Answer Key: D Feedback: The disease results in destruction of the motor neurons in the brainstem and spinal cord, causing gradual paralysis. Cognitive function is maintained. Because no cure exists for amyotrophic lateral sclerosis (ALS), interprofessional care is palliative and based on symptom relief. Death often occurs within 2 to 5 years after diagnosis
The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? A. Monocytes 4% B. Hemoglobin 13.6 g/dL C. Platelet count 168,000/µL D. White blood cell (WBC) count 15,500/µL
Answer Key: D Feedback: The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.
The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? A. Platelets of 95,000/µL B. Hemoglobin of 10 g/L C. Hematocrit of 30% D. White blood cell (WBC) count of 2700/µL
Answer Key: D Feedback: The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy.
The nurse is caring for a patient who has been diagnosed with stage I cancer of the colon. When assessing the need for psychologic support, which question by the nurse will provide the most information? A. "How long ago were you diagnosed with this cancer?" B. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon? C. "Do you have any concerns about body image changes?" D. "Can you tell me what has been helpful to you in the past when coping with stressful events?"
Answer Key: D Feedback: The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning.
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. transluminal angioplasty. B. intravenous heparin drip administration. C. surgical endarterectomy. D. tissue plasminogen activator (tPA) infusion.
Answer Key: D Feedback: The patient's history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
