Exam #5 Qs
The nurse is caring for a client diagnosed with a sensory incomplete spinal cord injury. The client asks the nurse to explain the injury. Which explanation should the nurse give?
Only sensory function will be present below the level of the injury.
The mother of a 12 YO expresses worry because the child is saying that the toy trucks are going to kill them and his moods have become unpredictable. The mother asks the nurse how to tell whether this is normal adolescent fantasy play, or if this might be a psychosis. How should the nurse respond?
"Adolescents and children with schizophrenia often have hallucinations or delusions related to their toys or to monsters." It can be difficult to determine the presence of hallucinations or delusions during childhood or adolescence, but actual hallucinations and delusions that toys are a danger should be further investigated as possible psychosis, especially if the child becomes increasingly fearful
The nurse is assessing a patient who has been diagnosed with schizophrenia. Which patient statement indicates the patient is experiencing an acute psychotic episode that may warrant hospitalization?
"Don't take my cardboard, it's all I have to protect myself from the police. I will kill them when they come to get me." The acute phase of schizophrenia is marked by the onset of florid psychotic/positive symptoms. If the behavior represents a danger to the individual or others, short-term hospitalization may be required.
The nurse is caring for a client with increased IICP from a cervical injury. Which statement by the nurse indicates an understanding of how to position the client?
"I will ask another nurse to help me lift the client toward the head of the bed." To prevent a further increase in ICP, the nurse should ask for assistance from another staff member. This prevents the client from pushing with their hands or feet against the bed, both of which can increase ICP. Prone position should be avoided; the HOB should be kept at 30 degrees to assist with venous drainage from the brain.
A client with HIV is being treated with a nucleoside reverse transcriptase inhibitor medication. The client asks the nurse, "How will I know if this drug is working?" Which response by the nurse is correct?
"If your CD4 count rises and your viral load decreases." although treatment may decrease viral symptoms, therapy is not evaluated by a lack of symptoms in a specific time period. Periodic blood tests will be performed to measure the effectiveness of therapy. A favorable response would show an increase in CD4 counts and a decrease in viral load.
A 45 YO experiencing hallucinations has just been diagnosed with late-onset schizophrenia. The patient asks the nurse what to expect from treatment. How should the nurse respond?
"Late-onset schizophrenia responds well to lower doses of antipsychotic meds, so the prognosis for management is good." Late-onset schizophrenia responds well to lower doses of antipsychotic meds. Symptoms are not as severe as in early-onset schizophrenia. Age-related changes in the brain may appear as possible very late-onset schizophrenia (VLOS), but that would not be the case in a patient in their 40s
The mother of twins asks the nurse questions about schizophrenia. One son has just been diagnosed with schizophrenia at 14, and the mother is concerned about the other son's risk of developing it. How should the nurse respond?
"Siblings have a higher risk of developing schizophrenia." Although initially diagnosed primarily in adolescents & young adults, schizophrenia may be diagnosed later in life. Having a first-degree relative with schizophrenia, like a parent or sibling, increases the risk of developing the disorder. Schizophrenia appears to be r/t multiple factors, & there is an identifiable genetic link. Other: Fam hx; father greater than 60 YO at the time of birth; birth complications; continuous exposure to stressors; stress during key developmental stages
The nurse is completing the health history of a patient with schizophrenia. How should the nurse evaluate the effectiveness of the treatment plan?
"Tell me how you are following your prescribed instructions." When evaluating the effectiveness of the treatment plan, the nurse should first consider the pt's compliance with the plan. If the pt has not been compliant, which is common in those with schizophrenia, the plan has not been implemented, and the effectiveness cannot be evaluated.
The nurse is teaching a new colleague the effects of drugs used for clients with SLE. Which statement by the colleague indicates the need for further teaching?
"When the client is on aspirin therapy, I should monitor for renal toxicity." Aspirin therapy may cause liver toxicity and hepatitis, not renal toxicity. Corticosteroid therapy can cause cushingoid effects. Aspirin is particularly beneficial for clients with SLE because its antiplatelet effects help to prevent thrombosis. Cytotoxic drugs can cause immunosuppression, placing the client at risk for infection, malignancy, and bone marrow depression.
The nurse is administering an oral antiseizure medication to an adult client. Which intervention should the nurse implement when administering this medication?
*Assess the pt for slurred speech. *Ask the pt for a list of home meds. *Monitor the pt for seizure activity
The nurse is caring for a client with IICP who is supported with mechanical ventilation. Which intervention should the nurse implement to ensure adequate oxygenation for this client?
*Implement measures to prevent atelectasis & fluid accumulation *Maintain partial pressure of arterial Co2 of 35 *Perform suction as needed *Maintain partial pressure arterial O2 of 100 **Judicious hyperventilation is only used as an emergency intervention for clients with IICP and impending herniation.
A client with newly diagnosed HIV states, "I don't know if I want to take the mediation. What's the point?" Which info should the nurse include when explaining the goals of pharm management to the client
*It will treat opportunistic infections & cancers. *It will decrease the symptoms. *It will prolong life for the affected person. *It will stimulate hematopoietic response
A pt reports to the nurse that they have not been feeling well & is concerned about being exposed to HIV. Which assessment finding supports a diagnosis of clinical stage 1 (acute) HIV infection?
*Malaise & flu-like symptoms. *Presence of arthralgia & myalgia *CD+4 T-lymphocyte count higher than 500/mm3. **Ataxia & oral hairy leukopenia are associated with later stages of infection.
The nurse is preparing a presentation on systemic lupus erythematosus (SLE). Which statement should the nurse include?
*Manifestations can be mild to fatal with remissions & exacerbations *SLE is a result of deposition of antigen-antibody complexes in connective tissues *The immune complex deposits trigger an inflammatory response. *Although the exact etiology of SLE is unknown, genetic, ethnic, environmental, and hormonal factors play a role in its development.
Which nursing goal is appropriate for a client with IICP
Protection from sudden increases in ICP. A major focus is protecting the client from sudden increases in ICP or decreases in cerebral blood flow.
Phases of Schizophrenia
*Premorbid: nonspecific developmental delays in childhood. *Prodromal: Alterations in functional or adaptive capabilities. *Acute: Onset of florid or psychotic s/s. *Residual: Aka maintenance phase, begins about 6-18 M after acute s/s. S/s are. under control but the pt is often exhausted & traumatized
During the initial interview, the nurse assesses the psychosocial history of a client diagnosed with HIV. Which info is the nurse seeking?
*Pt understanding of info r/t the condition. *Access to support systems. *Access to resources for future care. An initial psychosocial assessment is important to determine the client's developmental age and ability to understand the diagnosis, coping mechanisms, and support systems, as well as access to and availability of resources in order to provide competent care.
The nurse is caring for an adolescent experiencing a manic period of bipolar disorder. Which technique reinforces behavior limits?
*Speaking in a calm but matter of fact ton. *Building trust with the adolescent. *Modeling behavior for the adolescent to follow. *Curbing manipulative behavior
The nurse is planning discharge teaching for a 30 YO female client who was newly diagnosed with tonic-clonic seizures. Which info should the nurse include
*Take showers rather than baths (risk for drowing while having a seizure) *wear a bracelet that provides health info *Monitor the menstrual cycle *Avoid driving while taking antiseizure meds
The nurse is caring for a 59 YO who is recently divorced. The nurse understands that this client falls into the population of individuals who are called the "invisible population" due to which factor?
*Their HIV symptoms may be overlooked. *They are not comfortable talking about condom use. *They may not understand the importance of HIV testing.
The hcp has prescribed lithium carbonate for a client diagnosed with bipolar disorder. Which info should the nurse include in the client teaching?
*This med may be used with an anticonculsant used as a mood stabilizer *This med needs to be closely monitored by a hcp if you suspect that you may be pregnant *Lab work will be needed to monitor the therapeutic level *Monitor for n/v (this could be lithium toxicity)
50 YO with a newly diagnosed seizure disorder is depressed because they are not allowed to drive and have lost their independence. Which question should the nurse ask to support the client?
*Who is supporting you during this transition? *What kind of alternate transportations are you using? *How is not being able to drive affecting you? *What does being able to drive mean to you?
The nurse is assigned to care for four pts today in the clinic. Which client has the highest risk for contracting HIV infection?
60 YO male who has unprotected sex. HIV is becoming more prevalent in older adults due to inadequate knowledge of HIV transmission. They may not take preventive measures like using condoms, or may not feel comfortable discussing HIV/AIDS risk or condom use with their partners.
Which patient with schizophrenia is at the greatest risk for suicide?
A 22 YO male diagnosed 1 year ago. Younger age and more recent dx increase the risk of suicide in patients with schizophrenia. The symptoms, particularly the auditory hallucinations, are stronger, more frequent, and more distressing. Symptoms tend to become less severe over time, possibly due to age-related changes in the brain. An older adult person tends to have less severe manifestations of schizophrenia.
The nurse is preparing a client for surgery as a result of a traumatic injury. Which assessment finding indicates a need for the nurse to notify the hcp
A change in level of consciousness.
Which client is most at risk for developing respiratory difficulty?
A pt with injury at level of T6. Clients with injuries above T12 will experience some decrease in respiratory muscle control; the higher the level of injury, the more severe the deficiencies.
The nurse is caring for a client who has IICP from a TBI. Which diagnostic test should the nurse anticipate being ordered?
ABG; cardiac monitoring; ICP monitor; CT scan of head;
The nurse is preparing a teaching session for a community support group for clients who have been recently diagnosed with a seizure disorder. The nurse should include which factor as the cause of most seizures
Abnormal excessive electrical discharge from the cells of the brain.
Which altered physiological process contributes to the manifestations of schizophrenia?
Abnormalities in neurotransmitter function. The manifestations of schizophrenia, like visual and auditory hallucinations, occur as a result of abnormal neurotransmitter function and other brain abnormalities. Sensory organs will "detect" stimuli that are not there. There is decreased activity and decreased volume in the prefrontal cortex.
Which intervention is a priority to include in the plan of care for the client with bipolar disorder to prevent suicide?
Access to contact information for help in times of crisis.
Positive Symptoms
Additions to normal experiences include: Delusions. Hallucinations. Abnormal movements. Formal thought disorder.
The nurse is about to admin a mood stabilizer, antipsychotic, and antidepressant to a patient with schizophrenia. Which action should the nurse take in administering the meds?
Administer the meds because schizophrenia is usually treated with multiple meds and nonpharm therapies. Schizophrenia treatment is very complex, with other mental health comorbidities being treated as well, and the nurse should anticipate administering numerous types of meds. Commonly used meds for schizophrenia: Antipsychotics. Dopamine-serotonin system stabilizers. Antidepressants. Antianxiety agents. Mood stabilizers.
The lab results of a client with systemic lupus erythematosus (SLE) indicates anemia. Which collaborative therapy should the nurse anticipate?
Administering erythropoietin. For the client with anemia, meds such as erythropoietin may be given to stimulate red blood cell production. A splenectomy and the administration of corticosteroids are clinical therapies to treat thrombocytopenia. The underlying cause of the anemia is SLE. The disease cannot be cured, but the symptoms can be managed.
The nurse is admitting a client with a history of frequent tonic-clonic seizures. Which info would be most valuable for the nurse to obtain when performing the health history assessment?
Age of seizure onset; triggers for seizures; presence of auras.
Which assessment finding for a client should the nurse attribute to IICP
Altered LOC; slowed pupillary responses to light; decreased HR; decreased motor status & strength. Neuro assessments of a client with a head injury include assessment of the LOC. Decreased LOC will often be the first indication of an increase in ICP. Assessment of the vitals will reveal a slow HR and RR and increased BP. The motor status and strength will decrease.
Which med should the nurse expect to administer to the client with bipolar disorder for immediate treatment of the clinical manifestations of mania?
An antipsychotic mood stabilizer, olanzapine. An antipsychotic might be used for immediate treatment of manic manifestations. Lithium takes 1 to 3 weeks for effectiveness, so it is not an immediate help for current symptoms. Anticholinergic is given to treat the symptoms that result from antipsychotics. Antidepressants take 4 to 6 weeks to reach an effective level.
A patient diagnosed with schizophrenia is experiencing unrelenting anxiety. Which alternative therapy should the nurse recommend to the patient?
Aromatherapy. Aromatherapy helps to promote calmness. Transcranial magnetic stimulation is used to help decrease auditory hallucinations. Omega-3 fatty acids could help reduce the symptoms of tardive dyskinesia. Electroconvulsive therapy is generally used to treat depression.
A client is demonstrating signs of IICP. Which intervention should the nurse implement?
Assess cranial nerve function; assess vitals; monitor pupillary response; reduce environmental stimuli. Nursing actions for the client demonstrating signs of IICP nclude assessing vitals, monitoring pupillary response, assessing cranial nerve function, and reducing environmental stimuli. Intravenous fluids administered at this time would be isotonic or hypertonic.
The nurse is reviewing the medical record of a client with a diagnosis of AIDS-related dementia. Which clinical manifestation should the nurse expect to find during the physical assessment?
Ataxia, urinary incontinence, lethargy. AIDS-related dementia is the most common reason for mental status changes in the client with AIDS. The clinical manifestations: memory loss, confusion, & lethargy. As the disorder progresses, the client will develop ataxia (an abnormal gait) & incontinence
The nurse is teaching a client newly diagnosed with systemic lupus erythematosus (SLE). Which info should the nurse include in the client's teaching?
Avoiding large crowds. The pt should be advised to avoid large crowds to decrease exposure to infection. Instruct the pt to limit sun exposure and to use sunscreen with SPF 15 or higher when outdoors. The pt should take aspirin or ibuprofen for pain, but monitor for side effects of bleeding. The pt should be encouraged to use contraception to prevent pregnancy, because the prescribed drugs for treatment may increase the risk for birth defects.
Which is the primary life goal in long-term management of schizophrenia?
Being able to work, live, and function independently. Some pts with schizophrenia become homeless and receive fragmented care. The primary life goal of the treatment team is to assist the patient in establishing a permanent, stable living situation and a job.
Which complementary health approach may be specifically tailored to assist in the identification of the warning signs of seizures?
Biofeedback. Neurofeedback (biofeedback) techniques may be specifically tailored to help individuals with epilepsy identify the warning signs of seizures to prevent a seizure from developing
The nurse is caring for a client who is newly diagnosed with a seizure disorder. The nurse should anticipate which diagnostic test to be prescribed?
Blood chemistry; CBC; urine culture; lumbar puncture.
The nurse is planning care for an adolescent client with SLE. Which nursing diagnosis is a special consideration for this client?
Body Image, Disturbed. The adolescent client with SLE needs special consideration for body image disturbance, such as hair loss and moon face, resulting from the effects of medication for treatment of SLE
The nurse caring for a client with IICP should recognize that which compensatory mechanism stimulates the cerebral blood vessels to regulate cerebral pressure?
Carbon dioxide; carbonic acid; lactic acid. Lactic acid, carbonic acid, and carbon dioxide are chemicals that stimulate the dilation or contraction of blood vessels within the brain, which aids in regulation of cerebral pressure. Cerebral hemorrhage also regulates dilation or constriction of the cerebral blood vessels in response to the amount of blood flow within the brain.
The nurse assessing a client who presents with an altered level of consciousness (LOC) should suspect which condition?
Cerebral infarction; seizure activity; hematoma; TBI. Localized & systemic disorders can alter LOC. Processes occurring in the brain that may directly destroy or compress neurologic structures: IICP, cerebral infarction, hematoma, hydrocephalus, intracranial hemorrhage, tumors, infections, TBI, seizure activity, and recovery.
The nurse on the medical-surgical unit is providing care for a client with cervical SCI from an accident several years ago. The client reports a headache. Their BP is 230/115. Which intervention should the nurse provide?
Check their bladder; remove compression stockings; check for bowel impaction. The client has manifestations of autonomic dysreflexia. This is a medical emergency. A distended urinary bladder can cause it. If the bladder is causing the problem, the nurse can relieve manifestations by draining the bladder. A distended bowel can cause autonomic dysreflexia. If the bowel is the problem, the nurse can relieve the manifestations by removing the impaction. The compression stockings can contribute to autonomic dysreflexia by creating an irritation that causes the manifestations. The stockings also elevate BP by increasing venous return to the heart
The nurse should understand that cognitive-behavioral therapy focuses on which activity?
Cognitive modification; mindfulness; role playing; reflection. They focus on the client recognizing negative thinking and behaviors and refocusing them.
When reviewing the medical record of a client who experienced a SCI. the nurse notes that the client experienced the injury while diving into shallow water. Which type of excessive force does the nurse consider to have been placed on the vertebral column?
Compression. Compression occurs when excessive vertical force is applied to the spinal cord, such as in a diving accident. Transection of the spinal cord occurs when a force partially or completely severs the spinal cord. Excessive force in which the neck is forced backwards is hyperextension and is seen in whiplash injuries. Hyperflexion occurs when excessive force forces the head forward onto the chest.
The nurse is caring for a pregnant client with systemic lupus erythematosus (SLE). Which neonatal complication related to maternal lupus should the nurse anticipate the fetus to be tested for during the second trimester of pregnancy?
Congenital heart block (CHB). Congenital heart block (CHB) may occur in the fetus of a mother diagnosed with SLE. Fetal echocardiography may be used to assess for CHB in the second trimester of pregnancy. The prognosis for CHB varies, depending on when the congenital heart defect is detected. With treatment, early CHB may be reversible. but, late CHB could require the insertion of a pacemaker at the time of delivery
A client diagnosed with SLE presents with fatigue, joint pain, oral ulcers, and a red rash over the face and upper trunk. Which collaborative therapy should the nurse expect to implement?
Corticosteroid therapy. The nurse would expect corticosteroid therapy to be ordered. SLE is an autoimmune disorder, and corticosteroids and rest are the first-line treatment. Also, a priority treatment is rest, so the nurse would not expect PT to be ordered to improve mobility.
The nurse is part of an assertive community treatment (ACT) team caring for a home-based patient exhibiting extreme symptoms of schizophrenia and behaviors that have an immediate impact on the safety of the patient and others. Which type of collaborative intervention should the nurse anticipate will be needed?
Crisis intervention. Crisis intervention refers to short-term intensive measures implemented by the interprofessional ACT team, who are deployed to the site of the crisis for assessment and intervention. They address symptoms or behaviors that affect the immediate safety and equilibrium of the pt and others in the community. ECT Is not often used in schizophrenia, but may be effective in treating disorders such as depression and catatonia
The nurse is working with the activities director in a group home for clients with bipolar disorder. Which activity should the nurse include?
Dance; floor aerobics; walking. Competitive and aggressive activities like flag football or soccer should be avoided.
Which intervention should the nurse include in the plan of care for a client with a history of TBIs to determine worsening of the situation?
Determine level of orientation; ask to state their name & DOB; assess for new onset of self-care deficits; assess short & long-term memory changes.
Negative Symptoms
Diminished affects and behaviors include: Flat or blunted affect. Thought blocking. Avolition (lack of motivation). Poverty of speech. Social withdrawal.
The nurse is providing discharge instructions for a client with AIDS. Which instruction should the nurse emphasize?
Discharge instructions for a client with AIDS should focus on infection prevention and transmission, the importance of follow-up appointments and monitoring the immune status, s/s of opportunistic infections and cancer, and medication teaching to include side effects
The nurse is assessing a client with a traumatic head injury and suspects increased ICP. Which assessment finding supports this suspicion?
Double vision; drowsiness; blurred vision; hemiparesis. Hemiparesis or hemiplegia of the contralateral side may be an early sign of IICP. Drowsiness, double vision & blurred vision can occur with IICP. Headache is common with IICP. The client may also report other generalized manifestations such as dizziness. The heart rate generally decreases with IICP.
A client's husband asks, "What should I do if my wife has a seizure to keep her safe?" Which response by the nurse is correct?
During a seizure, placing the client in a side-lying position will help keep the client safe and promote oxygenation.
Which clinical manifestation should the nurse expect to find in a pta with a diagnosis of Pneumocystis jiroveci pneumonia?
Dyspnea, cough, fever. Pneumocystis jiroveci pneumonia is an opportunistic infection that can affect clients with HIV. The clinical manifestations include fever, cough, dyspnea, tachypnea, & tachycardia.
The nurse is teaching the parents of a 21 YO recently diagnosed with schizophrenia. Which action assists in decreasing the pt's likelihood of relapse?
Encouraging active listening. Active listening encourages effective communication, which decreases the likelihood of relapse. When voicing negative feelings, the family needs to use "I" instead of "you" when talking to the patient. The family needs to set limits to inappropriate behavior at all times.
The nurse is caring for a client with a C3 spinal cord injury who has diminished respiratory muscle control. Which intervention should the nurse include to promote adequate ventilation?
Encouraging frequent use of an IS; teaching to breathe deeply & cough every 2 hrs; provide cough-assist treatments
An emergency department nurse receives a client who reportedly has a C1 complete SCI. Which collaborative intervention should the nurse immediately prepare for the client?
Endotracheal intubation. A client with an SCI at level C3 or higher loses control of all four muscle groups needed for breathing. These individuals require immediate ventilator support.
A client asks the nurse what might trigger a seizure. Which situation should the nurse include in the response?
Exposure to toxins. The cause of seizures is unknown in up to 70% of those diagnosed with seizure disorder. However, they can occur after exposure to toxins as well as fever & IICP
The nurse is teaching a client about possible seizure triggers. Which info should the nurse include?
Fever; menstruation; specific odors; flashing lights.
A client has abnormal electrical activity that is contained to a limited area of the brain. Which type of seizure is the client experiencing?
Focal. Rationale: Focal seizures (also known as partial seizures) occur when abnormal electrical activity is contained to a limited area of the brain. Generalized seizures affect both hemispheres in the brain. Tonic-clonic and febrile seizures are types of generalized seizures, not focal seizures.
The nurse is teaching a client who has HIV about preventing secondary infections. Which action is most important for the nurse to include for helping the client prevent a secondary infection?
Frequently washing hands. Individuals who become immunosuppressed due to HIV are at risk for contracting secondary infections. The most important strategy to prevent infection is frequent handwashing using correct technique.
Which personal protective equipment should be utilized when using a bulb syringe to suction the nose of an infant infected with HIV?
Gloves, goggles, mask. When using a bulb syringe to suction the nares of an HIV-positive infant, the personal protective equipment should include masks, gloves, and goggles.
A client with a T4 spinal cord injury (SCI) calls the nurse to the room for bowel incontinence. The client cries, "I am so sick of this! Why is this happening to me? I just give up!" Which nursing diagnosis is the priority?
Grieving
A client with a spinal cord injury has no movement or sensation in the left side of their body. Which term does the nurse use to describe this condition?
Hemiplegia. Hemiplegia: paralysis of one-half of the body when it is divided along the median sagittal plane. Quadriplegia (tetraplegia): partial or complete paralysis of the upper extremities & complete paralysis of the lower extremities. Paraplegia: paralysis of the lower part of the body. Quadriplegia is a synonym for tetraplegia.
The nurse is preparing to discharge an older adult who was admitted to the hospital after hitting their head during a fall. Which service is most important for the client when at home?
Home assessment. Health promotion education for older adults includes fall prevention and adhering to cautions that accompany prescription meds. Older adults who are at risk for falls may benefit from a home safety assessment
A patient diagnosed with schizophrenia has been on medication, but still hears voices and is reluctant to tell the nurse what the voices say. The patient is clearly agitated and wants the voices to stop. Which is the clearest risk associated with the patient's disorder?
Homicidal thoughts and actions. Auditory hallucinations can lead to anger and hostility, thereby promoting homicidal thoughts and actions. Generally, auditory hallucinations often have threatening or accusatory content. Of individuals diagnosed with schizophrenia, an estimated 20-40% attempt suicide. Factors associated with this risk: Greater awareness of the illness. Younger age. Recent loss. Limited support. Recent discharge. Treatment failure.
The nurse is developing a plan of care for a client with urinary retention related to a flaccid bladder. Which intervention should the nurse include?
In & out catheterization as indicated; assessing bladder volume; beginning bladder training. A client who has a flaccid bladder will need assistance with bladder emptying to avoid bladder overdistention, bladder and kidney infection, and the development of kidney stones. Bladder training is possible in many clients depending on the level of the injury.
Which factor should the nurse recognize as an epigenetic factor that is associated with susceptibility and risk for schizophrenia?
In utero viral exposure. Most researchers agree that epigenetic factors must occur in order for schizophrenia to manifest. Many studies have focused on the impact of external events like birth complications, in utero viral exposure, poor prenatal care & marijuana use on gene expression in schizophrenia. Early life adversity like poverty, violence & trauma, have also been implicated in schizophrenia, but these are psychosocial factors. Children born to fathers who are 60 & older, have an almost twofold risk of developing the disorder, this is a genetic factor. There is evidence to suggest that children & adolescents who display certain alterations in emotional, cognitive, language, & motor development are at an increased risk for developing schizophrenia, this is a developmental factor.
The nurse is obtaining a health history for a pt with schizophrenia. The pt repeats "bad blank" over and over in response to all of the questions. Which is an appropriate course of action for the nurse to take, given the patient's impaired communication status?
Include family input, if possible. A pt with impaired communication is not likely able to provide info in a health history interview. Fam or support system input is important to understand the pt's functional status. If communication is impaired, functional status can be expected to be very low. Other nrsg interventions for the pt with impaired verbal comm: speak slowly & clearly; ask validating questions; use visual aids; ask specific questions to promote clarity.
The home health nurse is working with a family of a 10 YO who suffered a moderate TBI. Which info should the nurse provide to the parents to help them understand the changes that may occur due to this injury?
Increased lethargy; no interest in favorite toys.
The nurse is teaching a client who is HIV positive about needed immunizations. Which vaccination should the client obtain on an annual basis?
Influenza. The client who is HIV positive should receive an annual influenza vaccine to decrease the risk of obtaining the flu.
The healthcare team is discussing the care of a client with wasting syndrome secondary to AIDS. Which intervention would be appropriate for the nurse to include in the plan of care to address the client's nutritional needs?
Infuse TPN; review total protein & albumin levels; obtain daily weights.
A client presents with a head injury after being in a MVA and is diagnosed with a brain contusion with a coup-contrecoup injury. The client is stabilized and sent home, but the hcp instructs the client to return in 3 days for a repeat MRI. Which explains the rationale for a repeat MRI?
It can take hours to days for contusions to form from a coup-contrecoup injury. Brain contusions are classified as coup or contrecoup. Individuals can also have a coup-countrecoup injury. It can take a few hours to a few days to determine the full extent of the injury from these contusions. Therefore, the MRI would be repeated in a few days to determine the full extent of the injury.
The nurse is assessing a client with systemic lupus erythematosus (SLE). Which manifestation should the nurse recognize as a result of inflammation?
Joint pain, fever, malaise & maculopapular rash are all signs of the inflammation that result from local tissue damage.
The nurse preceptor is reviewing a plan of care created by a new graduate for a client with AIDS with a nursing diagnosis of Nutrition, Imbalanced: Less than Body Requirements. Which nursing intervention requires follow-up by the preceptor?
Keep the client NPO if diarrhea occurs. Diarrhea is a common occurrence for a client with AIDS. The client should not be NPO, but rather antidiarrheal medications should be administered after stools and the client should receive an antiemetic prior to meals. Reducing diarrhea improves nutrient absorption
An older client is beginning lithium therapy for newly diagnosed bipolar disorder. For which medical condition should the nurse review the chart before administering the prescribed medication?
Kidney insufficiency. The older adult with bipolar disorder is at risk of lithium toxicity in the setting of renal disease.
Which statement describes the use of laboratory testing in the diagnosis of schizophrenia?
Laboratory testing is used to rule out other etiology. There is not a definitive laboratory test for schizophrenia. Lab testing is used to rule out other etiology for specific symptoms. There are no serum levels or biomarkers that indicate schizophrenia. The PET scans in the image below show the difference between the brains of a normal pt and a pt with schizophrenia during a verbal fluency task
The nurse is providing discharge instructions for a client with bipolar disorder who presented to the hospital in a manic state. Which instruction should the nurse include?
Learn effective self-admin of meds; recognize med side effects; recognize the importance of adhering to therapy schedules; seek help when needed.
The nurse is reviewing the plan of care for a client brought in to the ER t after a motorcycle accident. The HCP suspects that the client has a diffuse axonal injury. Which test should the nurse anticipate being prescribed to confirm this diagnosis?
MRI scan. MRI will help the healthcare provider discern between a concussion and a traumatic brain injury (TBI), including a diffuse axonal injury.
A client is having a seizure. Which nursing intervention is of immediate importance?
Maintain the airway
The nurse working in the ER receives a client involved in a boating accident. Which should be the nurse's priority care for this client?
Maintaining the ability to breathe. Maintaining an airway is the priority for care in emergent situations. Once the airway has been established and stabilized, the priority would be preventing movement, preventing shock, and then stabilizing the spine with a brace or traction.
A client with bipolar disorder has only been prescribed an antidepressive medication. Which risk factor should the nurse consider to be the highest?
Manic episode. A pt with bipolar who is prescribed antidepressive medication has a high risk of having a manic episode in response to the antidepressant; to avoid this possibility, most clients with BPD who need an antidepressant will also take mood stabilizers.
The nurse is leading a group therapy session for pts with bipolar disorder. During the session, a pt with bipolar I disorder becomes increasingly restless & starts constantly interrupting & criticizing other members of the group. The pt ignores the nurse's repeated requests to stop the disruptive behavior. Which type of bipolar episode is the client likely experiencing?
Manic. The [t is likely experiencing a manic bipolar state. Mania is an abnormal & persistent period of increased, expanded, or irritable mood that is characterized by increased energy for a period of time. A depressive state is characterized by five or more symptoms in a 2-week period that demonstrate either a depressed mood or a decrease in pleasure or interest in daily activities.
cognitive symptoms of schizophrenia
Memory deficits. Attention deficits. Language difficulties. Loss of executive function.
The nurse is caring for a client with SLE who presents with pain and discomfort. Which treatment option should the nurse anticipate?
Moderate exercise, NSAIDs, corticosteroids. **NSAIDs are used to treat inflammation and pain in pts with SLE. A prescribed exercise plan can alleviate pain but must be balanced with adequate rest. Low-dose corticosteroids are used to reduce pain and inflammation in SLE. Improving nutrition promotes a well-balanced diet, improving overall health in pts, but does not specifically impact pain.
The nurse is caring for a client who has IICP and a fever of 102°F. Which nursing intervention promotes normal intracranial pressure?
Monitor LOC; provide supp O2; admin. acetaminophen per order. IICP can cause irregular & ineffective respirations. Supp O2 helps prevent hypoxia & excess CO2, which is a vasodilator. A decreased LOC can be a manifestation of pressure on the cerebral cortex. It can also be a manifestation of decreased O2 levels in the brain. Hyperthermia increases ICP & affects hypothalamic function in pts c increased ICP so giving an antipyretic is appropriate. Excess environmental stimuli can increase ICP. Flexing the neck increases ICP by preventing blood return from the brain. The head and neck must be kept in neutral position.
The nurse is teaching a client with a spinal cord injury. Which info should the nurse provide to help the client avoid autonomic dysreflexia?
Monitor urine for color & odor; avoid exposure to the sun; change positions frequently when sitting in a car; consume a high fiber diet with adequate fluid to prevent constipation; wear loose fitting clothes.
The nurse is reviewing medications with a client. The nurse should teach the client that which medication may cause drowsiness and increase the risk for a fall?
Narcotic analgesic. blood thinners may increase the risk of hemorrhagic stroke, and narcotic analgesics may cause dizziness and put the client at risk for falls. Antihypertensives may cause dizziness that can put a client at risk for a fall.
The school nurse is teaching a group of high-school football players about ways to prevent concussions and TBIs. Which info should the nurse include in this discussion?
Notifying the coach or other adult of head injury; avoid tackling headfirst; making sure the helmet is fitted based on head size; annual sports physicals
he nurse is caring for a client that presents with oral candidiasis related to HIV and AIDS immunosuppression. Which medication should the nurse expect the healthcare provider to prescribe?
Nystatin. The client with oral candidiasis would be prescribed nystatin swish and spit.
Which aspect should the nurse address in the psychosocial history assessment of a client with bipolar disorder?
Observation of client affect. During the psychosocial history assessment, the nurse will observe client affect
An ER nurse receives a client with a head injury. Which intervention is the priority in the care of this client?
Obtaining a baseline Glasgow Coma Scale assessment.
The nurse is assigning an unlicensed assistive personnel (UAP) to care for a client who has a TBI. The nurse explains the severity of the injury. Which aspect of the plan of care can the nurse delegate to the UAP?
Obtaining vitals every 15-30 minutes
The nurse is reviewing meds ordered for a newly admitted female client with systemic lupus erythematosus (SLE). Which med order should the nurse question?
Oral contraceptive. High-dose corticosteroids, immunosuppressants, and antineoplastic drugs are all used for the treatment of acute SLE. Caution needs to be taken with the use of oral contraceptives because estrogen triggers the symptoms of SLE.
The nurse is assessing a client with systemic lupus erythematosus (SLE). Which clinical manifestation should the nurse expect to observe?
Painful swollen joints, alopecia, red butterfly rash on the face, and leg and eye edema are all characteristics of SLE.
A 48 YO is being evaluated for late-onset schizophrenia. Which manifestations should the nurse expect the pt to have?
Paranoia, elaborate delusions, hallucinations. Late-onset schizophrenia is characterized by onset after age 40 & is manifested by paranoia, elaborate delusions, and hallucinations. Because the symptoms are not as severe, late-onset schizophrenia responds well to lower doses of antipsychotic meds. Disordered speech, motor deficits, and social withdrawal are more typical of early-onset schizophrenia.
The nurse is conducting a home visit for a 6 YO who has myoclonic and absence seizures. The parents are following a ketogenic diet for the child. Which observation requires follow-up by the nurse?
Parents include low-fat foods for each meal.. A keto diet is occasionally used for children under 8 who experience myoclonic & absence seizures. It is customized to the child to maintain ideal body wt, maximize ketosis & achieve optimal seizure control. The diet involves high intake of fat (up to 80% of calories), adequate intake of protein (1 g/kg), & low intake of carbs. urine ketone values should be monitored weekly or more frequently. Most common complications: constipation, hyperlipidemia, and kidney stones. Constipation can be treated with MCT oil & increased fluids.
A client with a history of systemic lupus erythematosus (SLE) anxiously states, "My chest hurts when I lie down. I think it is from coughing so much. Please sit me up." Which condition should the nurse first suspect?
Pericarditis. A client diagnosed with SLE is at risk for pericarditis. Clinical manifestations of pericarditis include chest pain radiating to the back, relieved by sitting forward and worsening when lying down, and a dry cough. ECG findings in pericarditis are an ST elevation and PR depression.
Which medical record should indicate to the nurse that the client has converted from being HIV positive to having fully contracted AIDS?
Pneumocystis jiroveci pneumonia. A pt has a diagnosis of AIDS when they develop Pneumocystis jiroveci pneumonia, tb, Kaposi sarcoma, or a weight loss of greater than 10% total body weight, or the CD4 count drops below 200/mm3. **Herpes zoster is seen in HIV-positive individuals in stage 2.
A patient who has had symptoms of hallucinations and delusional thinking is undergoing testing for possible schizophrenia. Which diagnostic testing could indicate possible schizophrenia?
Positron emission test (PET) scan of the brain. Although not usually performed for diagnostic reasons, PET scans of brain activity can show marked differences in brain activity in those patients with schizophrenia.
Which client is most at risk for IICP
Pregnant obese women; adolescent; newborn infant; school-aged child; older adult. Falls continue to be the major cause of TBI leading to IICP. Older adults are more prone to falls due to sensory & motor losses, as well as med use. Adolescents are at risk for MVCs and trauma resulting from violence. Premature newborn infants are at an increased risk of IICP. School-aged children are prone to falling. School-aged children are at risk for bicycle, swimming, or activity-related accidents that cause IICP. Obese women of childbearing age often have idiopathic intracranial HTN. During pregnancy, these women must be closely monitored for IICP.
Which assessment data should the nurse obtain when completing a health history on a client with a seizure disorder?
Presence of auras.
Which condition is an indication for decompression surgery for a client with spinal cord injury?
Progressive neuro deterioration; facet dislocation; spinal nerve compression. Spinal decompression surgery is most often performed in: progressive neurologic deterioration, facet dislocation (displacement of one vertebra on another), spinal nerve compression, and extradural lesions.
Which intervention is a priority to include in a plan of care for a patient with schizophrenia who is being discharged home?
Providing family teaching. Providing family teaching and support are a priority during discharge for this patient. When planning care for a patient with schizophrenia, the nurse needs to set limits on inappropriate behavior and provide an environment free from excessive stimulation
Which nonpharm intervention should the nurse implement to prevent the development of a DVT in a client who has tetraplegia?
Providing passive ROM.
The nurse is caring for a client with AIDS and has identified the problem of imbalanced nutrition. The client is currently underweight. Which intervention is appropriate for this client?
Providing supp vitamins; assist with oral hygiene; ID the cause of altered nutrition; provide foods high in protein & calories.
A 35 YO has been in the hospital for 2 weeks recovering from IICP. Which instruction should the nurse provide to the client?
Purchase a medical alert bracelet; take all meds as prescribed; discuss the care plan at the workplace.
The nurse is caring for a client who reports being hit over the head by their significant other. Which assessment finding should lead the nurse to suspect that the client has a skull fracture?
Raccoon eyes; clear drainage from nares; battle sign. Dysphagia and loss of consciousness can occur with moderate TBIs but are not distinctive to skull fractures.
In a community setting, the nurse is providing care to a client who was recently diagnosed with SLE. Which is the goal of care for this client?
Reducing pain; reducing inflammation; preventing infections; maintaining skin integrity.
A 39 YO who is a pastor informs the nurse about regularly hearing the voice of God ordering them to repent. He also states that the voice is very disturbing for him. How should the nurse respond?
Refer the pt for further workup of his auditory hallucination. Although hearing God speak may be a normal part of certain religious beliefs, it also requires further evaluation, particularly when it disturbs the patient. The health hx of a pt with possible psychosis should include: Deteriorating personal appearance. Weight loss. Unusual gestures. Speaking in sentences that make no sense. Visual and auditory hallucinations. Paranoia. Delusional thinking.
An older adult client is experiencing an acute episode of systemic lupus erythematosus (SLE). Which primary concern should the nurse consider when administering newly prescribed meds?
Renal function. Treatment for the older adult client is the same regardless of the age at onset of the disease. In addition to taking into consideration that older adults may be taking multiple meds, these individuals may have decreased renal function. Pharmacokinetics and drug-to-drug interactions need to be considered prior to the initiation of medications commonly used to treat SLE. Respiratory, neurological, and cardiovascular function are important, but the renal system remains a primary concern.
The nurse is caring for a client with systemic lupus erythematosus (SLE). Which system should the nurse consider as being most affected by the formation of immune complexes and tissue damage?
Renal. When the SLE autoantibodies react with their corresponding antigen, they form immune complexes, which are then deposited in the connective tissue of blood vessels, lymphatic vessels, and other tissues. These deposits trigger an inflammatory response that leads to local tissue damage. The kidneys are a frequent site of complex deposition and damage.
The behavioral health nurse is collaborating with the dietitian to create a diet plan for a client with bipolar disorder who is living independently. Which intervention should the nurse include?
Reviewing the use of nutritious meal-replacement drinks; ID easily prepared meals; make a list of pt food preferences; planning foods that are portable.
The nurse is planning care for a client with a complete lumbar spinal cord injury (SCI). Which problem diagnosis should the nurse expect?
skin integrity, risk for impaired; urinary incontinence, functional; self-care deficit.
The nurse is caring for a client who is 36 wks pregnant and sustained head trauma from a physical assault. The nurse initiated fetal monitoring, which shows that the fetus is healthy and viable, but the mother's condition is deteriorating. Which should the nurse prepare to perform next?
Scheduling a cesarean birth. If the fetus is healthy and viable at 36 weeks and the mother's condition is deteriorating, the delivery of the neonate by cesarean birth may take priority over the health of the mother.
The nurse is caring for a client with bipolar disorder who is admitted to the hospital after an accidental OD of sleeping medication. Which is an appropriate nursing diagnosis for this client?
Self-care, readiness for enhanced; coping, ineffective; knowledge, deficient; violence: self-directed, risk for
A client has been taking anticonvulsant medication for a seizure disorder. Which diagnostic test should the nurse expect the healthcare provider to prescribe?
Serum calcium. Antiseizure meds, such as phenytoin (Dilantin), can contribute to the demineralization of bone, and the serum calcium should be monitored.
The nurse working in a clinic discusses HIV prevention with an adolescent. Which behavior should the nurse instruct the adolescent to avoid to minimize the risk of contracting HIV?
Sharing needles, getting tattoos, having unprotected sex.
Which information regarding postconcussion syndrome and signs to report should the nurse provide to the client who sustained a concussion?
Signs of postconcussion syndrome include nausea, insomnia, headaches, personality changes, light and noise sensitivity, memory problems, dizziness, and fatigue
The nurse is discussing risk factors for spinal cord injury (SCI) with a community group. Which group should the nurse include as being high risk for this type of injury?
Single young adult man. Single young men are the individuals who are most likely to engage in risky behavior like diving into a too-shallow pool, not wearing protective gear while engaging in sports, or driving at high speeds. Non-Hispanic Caucasian Americans have the highest rates when race is compared
Which collaborative therapy should the nurse request when a client needs to learn to swallow following damage to the associated area of the brain?
Speech therapy
A client is experiencing a seizure and requires immediate intervention to preserve life. Which type of seizure is the client experiencing?
Status epilepticus. Status epilepticus is a continuous seizure that lasts for more than 30 mins or a series of seizures during which consciousness is not regained. Status epilepticus requires immediate intervention to preserve life.
The nurse is working with a client who sustained a TBI and is experiencing decreased mobility and decreased fluid intake. Which medication should the nurse expect the hcp to prescribe?
Stool softener. Clients with traumatic brain injuries (TBIs) can develop IICP from straining with bowel movements. That coupled with decreased mobility and fluid intake places the client at high risk for constipation.
A patient with schizophrenia has begun group therapy. The pt becomes increasingly agitated and anxious during the sessions and reports increased hallucinations. Which course of action should the nurse recommend?
Stop group therapy and begin individual therapy.. Some patients with schizophrenia will have difficulty in a group therapy session, especially if anxiety and hallucinations are common. Individual therapy will likely be more effective and less stressful for the patient.
The nurse is caring for a pt with bipolar disorder experiencing a depressive episode. The pt tells the nurse, "I don't know why I even try anymore. I always fail at everything in my life. I should just give up." Which aspect of the psychosocial history during the nursing exam is most important?
Suicide assessment. The nurse must assess the client for suicidal ideations because the client expresses thoughts of worthlessness
A client presents with an altered LOC resulting from a TBI. The MRI results show a large intracranial hemorrhage with a hematoma formation. Which collaborative intervention should the nurse anticipate?
Surgical evacuation
Medication has been ineffective in controlling a client's seizures. Which treatment option should the nurse suspect will be discussed with the client?
Surgical resection. Intractable seizures occur in 30% of clients with a seizure disorder. Surgery will be considered if the area of seizure focus (where the seizure activity starts) can be identified and is not responsible for any critical functions such as movement, sensation, or speech.
A client diagnosed with systemic lupus erythematosus (SLE) is experiencing pulmonary interstitial fibrosis. Which classification of lupus should the nurse suspect?
Systemic. There are three major classifications of SLE: discoid or cutaneous, systemic, and drug-induced. **Systemic lupus involves one or more of these systems: cardiovascular, central nervous, hematologic, kidneys, lungs, and musculoskeletal. **Cutaneous or discoid lupus is limited to the skin. **Many drugs can cause a syndrome that mimics lupus (drug-induced lupus).
Which collaborative process of initial monitoring should the nurse implement for a client who has been prescribed lithium?
Testing lithium serum levels every 1-3 days. The window between lithium toxicity and therapy is short, and close monitoring is required. (0.8-1.5)
The nurse is admitting a client with systemic SLE) for an upper respiratory infection. Which nursing goal is the priority?
The client demonstrates proper hand hygiene. The client demonstrating proper hand hygiene will reduce the risk of infection. *Alterations in skin integrity, including those in the oral cavity, can increase the risk of acute exacerbation of SLE. It is important for the client diagnosed with SLE to be able to verbalize the impact of the disease to the hcp in order to address the pt's psychosocial well-being.
Which nursing goal would be appropriate for a client who has a C2 spinal cord injury with resolving pneumonia?
The client will have ABGs within normal limits.. An appropriate goal for the client with resolving ventilation complications would be to have ABGs within normal limits. Oxygen saturations should be maintained at greater than 95%.
The nurse is developing a plan of care for a client with a TBI who sustained auditory damage. Which outcome is most appropriate for this client?
The client will wear hearing aid.
A non-English-speaking 25 YO Hispanic pt has begun behaving erratically and anxiously. The patient has become withdrawn and fearful. Which factor may complicate a diagnosis of schizophrenia?
The patient is from a different cultural background. Psychiatric diagnosis is based on clinical judgment and whether there is a deviation from social norms, so an individual from another culture may be difficult to diagnose. Certainly, the language barrier may make diagnosis more difficult, but translators may be used to facilitate communication.
A 24 YO is diagnosed with schizophrenia. Although he is participating in an occupational training program, his clothing is dirty and wrinkled, and he also has a distinct body odor. Which treatment goal is a priority?
The patient will complete ADLs appropriately.
The behavioral health nurse is assessing a client with bipolar disorder. Which finding indicates that the client is in a state of hypomania?
The pt expresses euphoric feelings of being on top of the world. Hypomania is less extreme compared with mania and does not involve manifestations of psychosis like hallucinations. The pt may feel like they are "on top of the world." Flight of ideas and hallucinations align with mania. Powerlessness & coping with alcohol may be observed with depression.
The nurse is assessing a pt with schizophrenia who was found wandering in the street. The pt is covered in dirt, is disheveled, and reports "going where the voices tell me to go." Which indications should the nurse use to recommend holding the patient involuntarily?
The pt is hallucinating & is not able to evaluate dangers, such as traffic. A pt who is hallucinating is unable to maintain their own safety, especially when the pt is oblivious to the world. Safety of the pt is priority & is a sufficient reason to recommend holding them. When a pt with schizophrenia is actively hallucinating, safety is the priority intervention. Other actions: Reassurance that they are safe; validation that their sensory perceptions are real but that they are not really happening; and support
An adolescent male patient has been diagnosed with early-onset schizophrenia. The nurse is preparing to discuss treatment options and care planning with the family. Which info about the early-onset schizophrenia should the nurse discuss?
There is a greater risk of long-term disability and an increased risk for suicide. Early-onset schizophrenia in adolescents is associated with a poor prognosis. This often results in the highest severity and the greatest amount of long-term disability. This is also associated with the highest risk of suicide. This type of schizophrenia does not resolve in adulthood, although symptoms may become less severe.
A client with a spinal cord injury is scheduled to receive a high dose of methylprednisolone. Which reason does the nurse recognize for administering this medication?
To decrease inflammation and reduce damage to surrounding nerve cells. The acute pain of traumatic injury is treated with opioids. To prevent DVT and PE heparin and warfarin (Coumadin) are given. Muscle relaxants are given to reduce muscle spasticity.
A client with IICP s prescribed mannitol. The family asks, "What is the purpose of this medication?" The nurse's response should be based on which action of the drug?
To draw fluid from the brain tissue. Mannitol is used in the treatment of increased intracranial pressure to draw fluid out of the brain, thereby reducing ICP
The nurse is requesting collaborative therapy from physical therapy for a client with IICP Which reason supports this request?
To recommend interventions for resulting hemiparesis or hemiplegia. The purpose of a physical therapy consult for a client with an alteration in intracranial pressure is to address the client's motor skills and strength in performing daily activities requiring mobility.
Which lab is used in the diagnosis of SLE?
UA; anti-DNA antibody testing; CBC; ESR. Labs that are used in the diagnosis of SLE are anti-DNA antibody testing to detect antibodies that occur in SLE, ESR to detect elevation related to SLE, serum complement levels to detect depletion by antigen-antibody complexes of SLE, CBC to detect anemia and overall pancytopenia, and urinalysis for abnormal traces of blood and protein indicating kidney dysfunction related to SLE.
A client is seen in the urgent care center with signs of a mild TBI. Which clinical manifestation would indicate a need to see a neurologist?
Unequal pupils. Unequal pupils indicate that the traumatic brain injury (TBI) was more severe than was actually diagnosed. This neurologic deficit would require further follow-up from a neurologist to determine possible cranial nerve damage or damage to the ocular portion of the brain.
The nurse admitting a client who was in a MVC is concerned that the client has a spinal cord injury with spinal shock. Which assessment finding would cause this concern?
Urinary incontinence; complete loss of sensation; flaccid paralysis. *Flaccid paralysis is expected finding during spinal shock. Pt will develop spastic movements later as edema from initial injury resolves. Complete loss of sensation is common during spinal shock. This occurs because of edema in area of the injury. Some sensation may return as edema resolves. Low BP is caused by lack of vasoconstriction needed to maintain it. This lack occurs because of damage to the nerve supply to peripheral blood vessels. Incontinence occurs because of damage to nerves that supply the bladder (may or may not be permanent depending on extent of damage). Spinal shock causes inability to regulate body temp. The body will assume a temp. similar to the temp. of the environment. P's skin would not be warm & flushed because of poor perfusion & low BP during spinal shock.
The nurse caring for a 76 YO is teaching home safety strategies prior to discharge. Which strategy should be taught to prevent the most common type of spinal cord injury (SCI) in the older adult population?
Using assistive devices such as a cane when needed for stability. Falls = most common cause of SCI in older adults. Therefore, a teaching strategy to prevent falls is indicated. Wearing seat belts, having daily checks, and participating in an emergency response system are important for safety in the older adult but will not prevent falls. Using assistive devices can help prevent falls.
The nurse is providing a presentation to a group of high-school-aged children and their parents regarding safety and TBI prevention. Which info would be most appropriate to provide to this age group?
Using seat belts. Adolescents have a high risk of developing TBIs related to motor vehicle collisions. It is actually the leading cause of death in adolescents
An alert client presents at the urgent care center after a fall. Which assessment should the nurse perform?
Vitals; LOC; pupillary size & reaction to light. Assessment of the neurologic status establishes the client's clinical condition and provides a baseline for measuring changes. Assessment areas include LOC, behavior, motor/sensory functions, pupillary size and reaction to light, & vitals
A client with a new diagnosis of HIV infection asks the nurse how to control the disease. Which statement is most accurate regarding HIV management to prevent disease progression?
You should take antiretroviral meds as prescribed. Once a pt is diagnosed with HIV, the HCP will prescribe antiretroviral therapy to attempt to eradicate or control the disease. Therefore, the nurse would instruct the pt to take antiretroviral therapy as prescribed. Obtaining routine imms, eating healthy, and exercising help maintain health but are not the most effective in preventing disease progression.
The nurse is developing a plan of care for a client who sustained a TBI. The client is having difficulty with meeting self-care needs, including dressing, bathing, and grooming. Which member of the healthcare team would help the client master these tasks?
occupational therapist (OT)
Which parameter should the nurse assess when administering pain medication to a client with a TBI?
respirations; pain level; heart rate; bowel sounds.
A client's mother asks the nurse if there is anything nonpharm that her daughter can do to help with intractable seizures. Which response by the nurse is correct?
"Eating a ketogenic diet can be helpful." The keto diet is a high-fat, low-carb, controlled-protein diet that has been used since the 1920s for the treatment of epilepsy. The diet is a medical treatment and is usually only considered when at least two suitable meds have been tried and have not worked
A parent brings a 12 YO to the clinic after a fall from a bicycle. Which statement by the nurse is a health promotion intervention to minimize future risk of IICP
"How do you feel about your child wearing a helmet while riding their bicycle?"
Which statement made by a 34-week pregnant client who is HIV positive indicates a need for further teaching?
"I plan to breastfeed my baby to save money on infant formula." When the pregnant client who is HIV positive states that they wish to breastfeed, it requires correction, because breastfeeding can increase the risk of disease transmission to the infant. Women who are HIV positive will undergo a c-section to decrease the risk of transmission. The newborn will begin zidovudine after birth to decrease the risk of seroconversion.
The nurse is caring for an adolescent who presents with headache, memory loss, and blurred vision after sustaining an injury playing football. The hcp diagnoses the client with a concussion and instructs the client to refrain from sports for a minimum of 4 wks to prevent second impact syndrome (SIS). Which client statement indicates an understanding of the instructions provided?
"I should stay away from any type of sports activity for a month." The client should not rely on headaches alone to go away before resuming sports, because this does not indicate that full healing has occurred.
The nurse is providing teaching for a client diagnosed with SLE experiencing alterations in skin integrity. Which client statement indicates effective teaching?
"I will limit the use of cosmetics." Cosmetics can irritate skin and increase the risk of integumentary symptoms. It is important for the pt's safety to use adequate lighting to prevent injury, and to specifically avoid fluorescent lighting. Fluorescent lighting has been linked to exacerbation of SLE. If the pt experiences alopecia, it is important that a wig is avoided when skin integrity is impaired. The pt should apply sunscreen 30 min prior to going out in the sun.
The nurse is teaching colleagues about cyclothymic disorder. Which statement should the nurse include?
"It involves a mood range from moderate depression to hypomania." Bipolar I disorder is characterized by at least one manic episode; the manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.
A client reports that they usually have a seizure on the first day of their period. Which response by the nurse is correct?
"Menstruation is a common trigger for seizures." There are many triggers reported by clients that elicit seizure activity. Commonly reported triggers include menstruation, flashing lights (such as strobe lights), and odors (such as a specific perfume).
A client is ready for discharge from the hospital after being treated for IICP. Which statement confirms that the client's spouse understands the discharge instructions?
"My spouse should avoid alcohol as it can increase the risk of injury." Nurses should instruct clients to avoid alcohol, which can increase the risk of injury, and products that contain nicotine, which increase the HR and BP and cause vasoconstriction that can increase the client's risk of stroke
The parents of a child with bipolar disorder ask the nurse what treatments will help control the child's violent outbursts and temper tantrums. Which would be the nurse's best response?
"Psychotherapy will help the child learn coping and appropriate actions to build relationships." The child with bipolar disorder may benefit from psychotherapy to learn how to react in social situations and build relationships.
A woman with bipolar disorder wishes to become pregnant and asks the nurse if she should stop the meds. Which would be the nurse's best response?
"Speak with your healthcare provider about tapering and changing some of your meds."
The nurse is caring for a client with exacerbation of SLE. Which statement by the nurse is accurate?
"The client is at risk for weight gain." The client is at risk for weight gain associated with the treatment involving steroids and a decreased activity level during exacerbation of the disease.
The nurse is caring for an older adult client who sustained a TBI who is schedule to be transferred to a rehab center after the acute phase of care is completed. The client asks the nurse what will be done for them there that cannot be done in a hospital. Which response by the nurse is most accurate?
"You will have different therapies tailored to meet your specific needs."
The nurse is caring for a pregnant woman who has a history of a complete L1 spinal cord injury. The client asks the nurse how to understand the onset of labor. Which is the nurse's correct response?
"You will need to watch for other symptoms of labor since you may not feel labor pains."
