Exam 3

The mother of a preschool-aged client tells the nurse that the client has frequent fevers. What is the best response to the mother?

"Fevers are seen more frequently in children because of developing immunity."

A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, '"I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse?

"I understand your concern. The blood is screened very carefully for different viruses as well as HIV."

A client recovering from a stroke is being discharged on oral Warfarin Sodium (Coumadin). During discharge teaching, which statement by the client would reflect an understanding of the effects of this medication?

"I will eat my usual amount of spinach while I am taking this medicine."

The health care provider recommends a carotid endarterectomy for a client with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The client asks the nurse to describe the procedure. Which response by the nurse is most accurate?

"The carotid endarterectomy involves surgical of plaque from an artery in the neck."

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?

"The client is unaware of his left side. You should approach him on the right side."

The nurse is caring for a client who practices Catholicism and was newly diagnosed with cancer. The client states, "God is punishing me for my past sins." What is the best response by the nurse?

"You sound upset. Would you like to talk about it?"

Antiretrovial medications as post exposure prophylaxis for health care workers are started within how many hours of exposure?

72 hours ...2 to 3 drugs are prescribed for 28 days -use standard precautions and hang hygiene to reduce the risk of transmission to HCP

Which client is more at risk for becoming infected with human immunodeficiency virus (HIV)?

A client having intercourse with multiple partners

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be appropriate for this client?

Absolute bed rest in a quiet, non-stimulating environment

a nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners

Which interventions would be recommended for a client with dysphagia? Select all that apply.

Assist client with meals as needed test gag reflect prior to offering food or fluids allow ample time to eat offer thickened liquids --you don't want to place food on the affected side of mouth

Which scenarios are examples of cultural competence? Select all that apply.

Attending a cultural diversity lecture series in the community Making arrangement for an acupuncturist to come to the hospital and provide pain relief for the client Having a one-on-one conversation with a client regarding prayer needs and practices Performing a self-assessment of one's own personal biases

a client is receiving alteplase (Activase) following a stroke. Which effects are more likely attributed to this drug?

Bruising and epistaxis

A nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematous (SLE). What skin manifestation would the nurse expect to observe on inspection?

Butterfly rash

The clinic nurse assesses a client with a history of transient ischemic attacks (TIA). This client is at an increased risk for which disorder?

Cerebrovascular accident (CVA)

A client presents to the emergency department when a body temperature of 104 degrees F. Which interventions would be appropriate? Select all that apply.

Cover the client with a fluid-circulating cooling blanket ensure a cool environment monitor intake and output

A nurse is working to develop cultural competence. Which activities would be appropriate for the nurse to engage in when exploring the nurse's own cultural awareness? Select all that apply.

Critical Reflection Feedback from colleagues self-assessment

The nurse planning care for a client admitted with a stroke would include which interventions to support the client's sensorimotor needs?

Encourage use of non-affected arm to feed self, bathe, and dress

What clinical syndrome is characterized by a progressive decline in cognitive, behavioral, and motor functions as a direst result of HIV infection?

HIV encephalopathy

A 7-year-old with a head injury is hospitalized after loosing consciousness. The last set of vital signs showed heart rate 48, blood pressure 148/74, and respiratory rate 12 and irregular. The nurse concludes these are symptoms of what potential problem?

Increased intracranial pressure

The nurse is administering oxygen to a client experiencing a stroke in order to prevent hypoxia and hypercapnia. This intervention will also lessen the risk for which complication?

Increased intracranial pressure (ICP)

A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (Activase). What is true regarding the use of this medication?

It is administered to dissolve the clot that is occluding the cerebral circulation

A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action?

Maintain an open airway

A client with right-sided weakness that started one hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first? a. Non-contrast computed tomography (CT) scan b. chest radiograph c. complete blood count (CBC) electrocardiogram (ECG)

Non-contrast computed tomography (CT) scan

The client diagnosed with a right-sided cerebrovascular accident (CVA) is admitted to the rehabilitation unit. Which interventions should be included in the nursing plan of care? Select all that apply.

Position the client to prevent shoulder adduction refer the client to occupational therapy encourage the client to move the affected side perform quadriceps exercises five time a day

The nurse identifies the nursing diagnosis of impaired verbal communication for a client with expressive aphasia. Which intervention would help the client communicate?

Provide a communication board, which includes common needs and phrases

The nurse is providing diet-related advice to a male client following a cerebrovascular accident (CVA). The client wants to minimize the volume of food and yet meet all nutritional elements. What suggestion should the nurse give to the client about controlling the volume of food intake?

Provide thickened commercial beverages and fortified cooked cereals

A client with cerebral edema is prescribed intravenous mannitol (Osmitrol). What is the expected action of mannitol?

Reduce fluid in the cerebral tissue

A patient's decreased mobility is ultimately the result of an autoimmune reaction origination in the synovial tissue, which caused the formation of panes. This patient has been diagnosed with what health problem?

Rheumatoid Arthritis

A client has a stroke affecting the right hemisphere of the brain. Based on the knowledge of the effects of right brain damage, what is the priority nursing diagnosis for this client?

Risk for injury related to denial of deficient and impulsiveness

The nurse caring for several clients on a surgical unit notes that one of the clients is Muslim. The nurse decides to remove all pork from the client's meal tray prior to delivering it to the room. What best describes the nurse's action?

Stereotyping

When developing a plan to decrease stroke risks, which risk factor is most important for the nurse to address?

The client's blood pressure (BP) is chronically around 170/90 mmHg

An elderly client admitted with pneumonia has a normal body temperature. The nurse realizes the reason for this inconsistency is based upon which rationale?

The temperature is not a reliable indicator

A client with a history of several transient ischemia attacks (TIAs) arrives in the emergency room with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipated the need to prepare the client fro which procedure?

Tissue plasminogen activator (tPA) infusion

Which signs and symptoms are early clinical manifestations of increased intracranial pressure (ICP)?

disorientation and restlessness

The nurse is conducting a teaching clinic for senior citizens about risk factors for stroke. Although the nurse includes all of the following as risk factors, which one presents the greatest risk for stroke? a. hypertension b. heart disease c. diabetes d. high cholesterol level

hypertension

What is a contraindication for the administration of tissue plasminogen activator (t-PA)?

intracranial hemorrhage

When could a "rebound" anaphylactic reaction occur after an initial attack even when epinephrine has been given?

it can occur 4 to 10 hours after initial attack even when Epi has been given

A client presents to the Emergency Department with right-sided weakness and slurred speech for the past 3 hours. What is the probable cause of the neurologic deficit?

left-sided stroke

What are the modes of transmission of HIV

transmitted in body fluids that contain infected cells: blood and blood precuts, seminal fluid, vaginal secretions, mother to child (amniotic fluids, breast milk)....Not through casual contact