Exam 3 Review Questions

Which is the best method for the nurse to use to communicate with the patient experiencing receptive aphasia?

Use gestures, standing where the patient can see.

A nurse in an oncology clinic is caring for a client who is undergoing tx for cancer & reports difficulty eating due to inability to taste food. What interventions should the nurse recommend?

Use plastic utensils

A community health nurse is assessing a client who reports numbness of the hands & feet for the past 2 weeks. The finding is associated w/ which of the following nutritional deficiencies?

Vitamin B12

The nurse knows the patient understands teaching about an angiogram when the patient makes which of the following statements?

"A catheter will be placed in an artery in my groin, and dye will be injected that will make my vessels show up on x-ray."

A patient with amyotrophic lateral sclerosis expresses concern about not having enough breath to sing anymore. Which explanation by the nurse is best?

"Amyotrophic lateral sclerosis may be affecting the nerves that go to your respiratory muscles, making them weak."

A patient with trigeminal neuralgia asks the nurse why carbamazepine (Tegretol) has been ordered. Which response is best?

"Carbamazepine is used to help relieve nerve pain."

Which instruction would the nurse provide for the patient when testing the trigeminal nerve?

"Close your eyes and tell me where you feel the cotton touching your face."

A nurse is obtaining a health hx from a client who is being evaluated for the cause of frequent headaches. What questions should the nurse ask to identify the aura type of migraine headaches?

"Do you have the same manifestations each time the headache occurs?"

A nurse is providing teaching for a client who has a new diagnosis of HTN & a prescription for a low-sodium diet. What statement indicated understanding of the teaching?

"I need to read food labels when grocery shopping."

A nurse is teaching a client about dietary recommendations to lower high BP. What statement indicates understanding?

"I should consume low-fat dairy products."

A nurse in a clinic is reinforcing teaching to a client who has a hx of migraine headaches about a new prescription for zolmitriptan. What statement by the client indicates understanding?

"I should expect facial flushing when I take this medication."

A nurse is teaching a client who is undergoing cancer tx about interventions to manage stomatitis. What statement indicates understanding?

"I will avoid toasting my bread."

A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if this same type of tumor can occur in other areas of the body. How should the nurse respond?

"It is limited to brain tissue."

A patient makes an appointment to see a health care provider for recurrent severe headaches. Which instruction by the nurse will help gather the best additional data before the appointment?

"Keep a diary of your headaches, recording symptoms, timing, and headache triggers."

A nurse is reviewing dietary recommendations with a group of clients at a health fair. What info should the nurse include?

"Make protein 10% to 35% of total calories each day."

A nurse is reinforcing teaching to a client who has multiple sclerosis and a new prescription for baclofen. What statements should the nurse include?

"This medication can cause you to experience dizziness."

A nurse is reinforcing teaching to the partner of a client who has Alzheimer's disease & has a new prescription for Donepezil. Which of the following statements by the partner indicates the instruction is effective?

"This medication should help my husband's daily function."

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. What are appropriate statements by the nurse?

-"It is given to reduce swelling of the brain" -"You might notice weight gain" -"It can cause you to retain fluids"

Which nursing interventions are appropriate for the patient with Bell palsy?

-Administer moisturizing eye drops -Apply an eye patch -Apply warm compresses. -Provide facial massage.

A nurse is collecting data from a client who has PUD. What finding is expected?

-Anemia -Tarry stools -Epigastric pain

A nurse is reviewing info about a new prescription for corticosteroid cream with a client who has mild psoriasis. What instructions should the nurse include?

-Apply an occlusive dressing after application -Wear gloves after application to lesions on the hands -Avoid applying in skin folds

A nurse is collecting data from a client who has a diagnosis of multiple sclerosis. What finding should the nurse expect?

-Areas of paresthesia -Involuntary eye movements -Ataxia

A nurse is planning care for a client who has mechanical fixation of the jaw following a motorcycle crash. What action should the nurse include in the POC?

-Assist the client to use a straw to drink liquids -Encourage intake of fluids between meals

A nurse is teaching a client about high-fiber foods that can assist in lowering LDL. What foods should the nurse include?

-Beans -Whole grains -Broccoli

Which nursing interventions are appropriate for a patient with a circumferential burn to an extremity?

-Check neurovascular status hourly. -Assist with escharotomy if indicated. -Elevate the extremity.

A nurse in a provider's office is obtaining a health history from a client who has cluster headaches. What are expected findings?

-Client experiences sleep-wake cycle. -Headache occurs approximately 1-8 times a day -Nasal congestion & drainage occur

A nursing is planning care for a client who is receiving tx for malnutrition. The client is scheduled for discharge to their home where they live alone. What actions should the nurse include in the POC?

-Consult social services to arrange home meal delivery. -Advise the client to purchase frozen fruits & veggies -Recommend drinking a supplement between meals -Educate the client on how to read nutrition labels

Which of the following are modifiable risk factors that should be taught to patients at risk for stroke?

-Diabetes -High cholesterol -Obesity

A nurse is collecting data from a client who has ICP. What findings are expected?

-Disoriented to time and place -Restlessness & irritability -Unequal pupils -HA

A nurse is assessing a client who his post-op from a gastric bypass & who just finished eating a meal. What finding is manifestations of dumping syndrome?

-Dizziness -HOTN -Diarrhea

A nurse is teaching a community program on nutritional guidelines for cancer prevention. What instructions should the nurse include?

-Eat high in vit A foods -Add cruciferous veggies -

What interventions can help prevent aspiration in a post-stroke patient with dysphagia?

-Ensure that the patient is fully alert before feeding. -Place the patient in high-Fowler position or chair for meals. -Use a thickening agent

A nurse is caring for a client who has Alzheimer's disease. A family member of the client asks the nurse about risk factors of the disease. What should be included in the nurse's response?

-Exposure to metal waste products -Previous head injury -Hx of exposure to toxins

What assessments are included in the 4 score coma scale?

-Eye response -Motor response -Brainstem reflexes -Respiration

A nurse is planning care for a client who has dysphagia & a new dietary prescription. What should the nurse include in the POC?

-Have suction equipment available -Feed the client thickened liquids -Place the food on the unaffected side of the client's mouth -Reinforce the client to swallow with the neck flexed

A nurse is assisting with the care of a client who is having surgery for the removal of an encapsulated acoustic tumor. What potential complications should the nurse monitor for postoperatively?

-ICP -Hydrocephalus -Seizures

A nurse is assisting with the care of a client who has experienced a right-hemispheric stroke. The nurse should expect the client to have difficulty with which of the following?

-Impulse control -Moving the left side -Depth perception

A nurse is contributing to the POC for an adult client who sustained severe burn injuries. What interventions should the nurse recommend for inclusion in the POC?

-Limit visitors in the client's room. -Increase protein intake -Restrict fresh flowers in the room

A nurse is providing teaching to a client who has vitamin B12 deficiency. What food should the nurse instruct the client to consume?

-Meat -Eggs -Milk

A nurse is teaching a client who is recovering from pancreatitis about following a low-fat diet. What food should the nurse recommend?

-Oatmeal -Canned peaches -Pretzels

A nurse is collecting data on a client for manifestations of Parkinson's disease. What are expected findings?

-Pill-rolling tremor of the fingers -Shuffling gait -Drooling -Lack of facial expression

The nurse identifies which of the following as normal effects of aging on the central nervous system?

-Reduced blood flow to the brain -Impaired short-term memory -Decrease in acetylcholine

A nurse is making a home visit to a client who has AD. The client's partner states that the client is often disoriented to time & place, is unsteady, and has a history of wandering. What safety measures should the nurse review with the partner?

-Remove floor rugs -Provide increased lighting in stairwells -Install handrails in the bathroom -Place the mattress on the floor

A nurse is discussing health problems associated with nutrient deficiencies with a group of clients. What conditions is associated with vit C deficiency?

-Scurvy -Bleeding gums

A nurse is caring for a client who has global aphasia (both receptive & expressive). What should the nurse include in the client's POC?

-Speak to the client at a slower rate. -Assist the client to use cards with pictures -Give instructions one step at a time

A nurse is collecting data from a client who sustained deep partial-thickness & full-thickness burns over 40% of the body 24 hours ago. What are the findings common in this phase?

-Temperature 36.1 C/97 F -Hyperkalemia -Hyponatremia

Which patients should be closely monitored by the nurse for symptoms of increased intracranial pressure?

-The patient admitted with a high fever and severe headache -The patient in the postanesthesia care unit following craniectomy -The patient with a brain tumor who is admitted for radiation therapy

A nurse is teaching a client who has cancer about ways to increase protein & calories in foods. What actions should the nurse include?

-Use peanut butter as a spread on crackers -Top fruit w/ yogurt -Dip chicken in eggs before cooking -Sprinkle cheese on a baked potato

How soon after symptom onset must a person who is having a stroke receive thrombolytic therapy?

2 hours

A nurse is discussing foods that are high in vitamin D with a client who is unable to be out in the sunlight. What should be included in the teaching?

2 large, poached eggs

A patient is admitted to the emergency department with flame burns to the entire chest, abdomen, back, and upper extremities. Using the Rule of Nines, what approximate percentage of burns should the nurse document?

54%

A college student is admitted to the hospital with a severe headache. Which finding in the student's history is consistent with the diagnosis of meningitis?

A sore throat for 3 days

A nurse is reinforcing teaching with a client who has a history of psoriasis about photochemotherapy & ultraviolet light (PVA) treatments. What instructions should the nurse include?

Administer a psoralen medication before the treatment

A nurse is caring for a client who has contact dermatitis & has a new prescription for diphenhydramine. For which of the following adverse effects should the nurse monitor?

Anorexia

A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. What instructions should the nurse include?

Apply a cool cloth to the face during a headache.

Which of the following nursing interventions should be included in the plan of care for a patient at risk for foot drop?

Apply high-top tennis shoes.

A patient who is newly diagnosed with amyotrophic lateral sclerosis says to the nurse, "I do not want to be kept alive on machines." Which nursing action is best in response?

Ask the patient whether advance directives have been prepared and provide information if indicated.

A patient is brought to the emergency department after a house fire. The patient has extensive trunk and lower extremity burns and is diagnosed with a deep partial-thickness burn. What assessment findings does the nurse expect?

Blistered, pinkish-white, painful lesions

A nurse is teaching a client who has constipation about high-fiber, low-fat diet. What food choice indicates understanding?

Brown rice

A nurse is reinforcing teaching with a client on the use of calcipotriene topical medication for the treatment of psoriasis. What lab values should the nurse monitor?

Calcium

When performing a neurologic assessment, which of the following is a symptom of increasing intracranial pressure that the nurse should immediately to the primary care provider?

Decreasing LOC

A nurse is doing an afternoon assessment on a patient transferred to a medical unit from intensive care following a subarachnoid hemorrhage. The patient was alert and oriented during the morning assessment but reported being very tired. Now the patient is difficult to arouse. What action should the nurse take?

Call the RN immediately.

A patient is admitted following a T4 spinal injury. When taking morning vital signs, the nurse notes that the patient appears restless and that blood pressure is elevated. Which of the following actions by the nurse is appropriate?

Check for a full bladder or bowel.

A nurse is caring for several clients in an extended care facility. What clients is the highest priority to observe during meals?

Client w/ Parkinson's

A patient with meningitis has photophobia and a severe headache. Which nursing interventions will be most helpful to relieve symptoms?

Darken the room & administer analgesics

A nurse is educating a client who has anemia about dietary intake of iron. What is a non-heme source of iron?

Dried beans

A patient has returned from having a computed tomography scan with contrast. Which of the following should be a priority in the hours after the scan?

Drinking fluids

A nurse is caring for a client who is transitioning to an oral diet following a partial laryngectomy. What action should the nurse take to reduce risk for aspiration?

Encourage the client to tuck the chin when swallowing

A nurse is caring for a client who has Parkinson's disease & is starting to display bradykinesia. Which of the following is an appropriate action by the nurse?

Give the client extra time to perform activities.

A nurse is instructing a client who has celiac disease about foods to avoid. What should the nurse include?

Graham crackers

Which nursing interventions are appropriate for the patient with a neurodegenerative disorder who has difficulty swallowing?

Have the patient tuck his or her chin down during swallowing.

A patient with a history of seizures reports experiencing an aura and is concerned about an impending seizure. Place the nurse's interventions in the correct order.

Help the patient lie down in a safe place.

A nurse is assisting with the care of a client who sustained deep partial-thickness & full-thickness burns over 60% of their body 24 hours ago and is requesting pain medication. The nurse should ensure the medication is administered using which of the following routes to administer the medication?

IV

When caring for a patient admitted with Guillain-Barré syndrome, which nursing diagnosis should take priority?

Impaired Gas Exchange

A nurse is collecting data on a client. What findings indicates that the client has experienced a left-hemispheric stroke?

Inability to recognize familiar objects

A nurse is caring for a client who has sustained burns over 35% of total body surface area. The client's voice has become hoarse, a brassy cough has developed, & the client is drooling. The nurse should identify these findings as indications that the client has which of the following?

Inhalation injury

Which of the following actions should the nurse take to help prevent increased intracranial pressure in a patient following a traumatic brain injury?

Keep the head of the bed elevated at 30 degrees.

Which of the following actions is appropriate initial treatment of a chemical burn?

Lavage with water.

A patient who has had a generalized tonic-clonic seizure is sound asleep 30 minutes after the seizure. Meals are about to be delivered. Which nursing action is most appropriate?

Let the patient sleep during the postictal state, and keep the meal warm.

A nurse is caring for a client who has multiple sclerosis. What finding should the nurse expect?

Loss of cognition fx

Which meal would be the best choice for a patient with myasthenia gravis?

Meatloaf, mashed potatoes, canned green beans

A nurse is reviewing a client health record that includes a report of abdominal obesity & laboratory findings of elevated glucose & elevated triglycerides. These findings meet the criteria of what condition?

Metabolic Syndrome

A nurse is caring for a client who had just undergone a craniotomy & has a RR of 12. What postoperative prescriptions should the nurse clarify with the provider?

Morphine sulfate 2 mg IV bolus PRN Q2H for pain

How will the nurse know if interventions for impaired gas exchange related to smoke inhalation have been effective?

Partial pressure of oxygen (PaO2) is 88 mm Hg.

A nurse is caring for a client who has left homonymous hemianopsia. What intervention should the nurse make?

Place the bedside table on the right side of the bed

A nurse is reinforcing teaching with the guardian of a child who has contact dermatitis. What info should the nurse include?

Place the child in a bath with colloidal oatmeal

A nurse is caring for a client who has AD & falls frequently. What actions should the nurse take first to keep the client safe?

Place the client in a room close to the nurse's station

A nurse is contributing to the POC for a client who has Parkinson's disease. Which of the following actions should the nurse include?

Record diet & fluid intake daily

A nurse working in a long-term care facility is contributing to the POC for a client who has moderate Alzheimer's (mild or moderate stage). What intervention should be included in the POC?

Reorient the client to self & current events

A nurse is collecting data from a client who has suspected HIV-associated muscle wasting. What finding supports this diagnosis?

Report of fever for 30 days.

A nurse is reinforcing teaching with a client who has Parkinson's Disease & has a new prescription for bromocriptine. What instructions should the nurse include?

Rise slowly when standing

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should instruct that which of the following foods can trigger a migraine headache?

Salted peanuts

A resident of a long-term care facility who has Alzheimer disease is sitting in a corner, crying loudly that no one is paying attention. Several staff members have tried to find out what's wrong, but the patient won't answer and just keeps rocking back and forth and crying. Which approach by the nurse might best help the patient?

Sit quietly by the patient and say, "I'm here. You aren't alone."

A nurse in a provider's office is collecting data from a client who has a severe sunburn. What classification should the nurse use to document this burn?

Superficial thickness

How will the home health care nurse caring for a patient with myasthenia gravis and severe muscle weakness know if interventions have been effective?

The patient is able to perform activities of daily living with oxygen saturation remaining at 95%.

A nurse is conducting a nutritional class on minerals & electrolytes. The nurse should include which of the following foods is a major source of magnesium?

Tuna

A nurse is caring for a patient who is recovering from an ischemic stroke. Upon entering the room to pick up the supper tray, the nurse notes that the patient has only eaten food on the left side of the tray. What should the nurse do?

Turn the plate 180 degrees and observe the patient's response.