Exam 5 Study Guide
Friends come to visit a client admitted with new-onset ischemic stroke. The stroke has caused aphasia and right-sided weakness. The client has an advance directive and an identified healthcare power of attorney. The friends ask the nurse about the client's condition. How should the nurse respond?
"I'm not at liberty to discuss their condition with you. You'll have to speak to the client's power of attorney if you'd like information."
A client with a new diagnosis of myasthenia gravis asks, "What is happening to me?" What would be the most appropriate response by the nurse?
A chronic disease in which there is a disturbance in nerve transmission to the muscle, resulting, in fatigue and muscle
In which circumstance may the nurse legally and ethically disclose confidential information about a client?
A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency
The children of an elderly client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their parent's bedside tomorrow to make recommendations for client's care. Which considerations should the nurse prioritize in light of the practitioner's planned visit?
Ensuring that the complementary therapies are safe when combined with his prescribed therapy
A client at risk for deep vein thrombosis (DVT) is prescribed antiembolism stockings. What should the nurse instruct the client about the purpose of these stockings?
Promotes venous blood in the lower extremities
The nurse observes a visitor having a tonic-clonic seizure on the floor in the hallway of the acute care floor. What is the nurse's appropriate intervention when caring for the visitor?
Protecting the visitor's head with a pad to prevent injury
When assessing the client with Parkinson's disease, the nurse should observe the client for:
a stiff, masklike facial expression
A client admitted with acute pyelonephritis now reports having a severe migraine, but declines PRN analgesics. What should the nurse discuss with this client? Select all that apply.
Ask the client which migraine treatments are helpful when at home. Alternative therapies such as relaxation or music can help.
A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac catheterization that involved a femoral puncture. The client is reminded to keep their leg straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is responsible for three other clients who underwent cardiac catheterization. What's the best step the nurse can take?
Ask the staffing coordinator to assign a nursing assistant to sit with the client
The nurse is assisting a client from the bed to a chair when the client begins having a generalized seizure. Which action should the nurse take first?
Assist the patient to a side lying position on the floor.
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?
Establish a regular voiding schedule
Which action should be the priority when caring for a school-age child admitted to the pediatric unit with the diagnosis of Guillain-Barré syndrome?
Evaluate the child's bilateral muscle strength.
The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?
Explain how to overcome a freezing gait by telling the client to march in place
A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)?
Identify the time of onset of the stroke
A client is discharged to home following hospitalization for percutaneous endoscopic gastrostomy tube placement to assist with nutrition. The client's primary diagnosis is amyotrophic lateral sclerosis (ALS). The client can transfer from the bed to a chair but can't walk. The client and their family are concerned about the client's ability to maintain mobility at the highest possible level following a surgical procedure. The nursing diagnosis most appropriate for this client is
Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate.
A client presents with severe headache, blurred vision, anxiety and confusion. The client's blood pressure is 224/137 mm Hg. The family reports that the client has hypertension, but has not been taking the prescribed blood pressure medications. The nurse anticipates giving which medication?
Labetolol
A client with quadriplegia is experiencing severe muscle spasms. To relieve them, a physician orders baclofen, 5 mg P.O. three times daily. What is the principal indication for baclofen?
Muscle spasms with paraplegia or quadriplegia from spinal cord lesions
A home health nurse is visiting a client with Alzheimer's disease who lives with two adult children. The nurse notes bruising on the client's upper arms. The client is more withdrawn than normal and is unable to communicate effectively because of the disease. What is the priority action by the nurse?
Report suspicion of elder abuse to the local agency on aging
A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside?
Suction machine with catheters
When the nurse is obtaining a health history from an older adult, which information in the history is a risk factor associated with deep vein thrombosis (DVT)?
The patient recently had abdominal surgery
The nurse observes that when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors?
The tremors sometimes disappear with purposeful and voluntary movements
The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which intervention should the nurse consider?
Thickening all liquids before offering to the client
Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client?
a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance
Which patient should the nurse see first?
a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain
A client has been admitted to the emergency department. The client's family tells the nurse that the client has suddenly become lethargic and is "not making sense." The client has not had anything to eat or drink for the last 8 hours. The nurse further assesses the client using the Confusion Assessment Method (CAM). The client's responses to questions are rambling, and the client is not able to focus clearly to answer the nurse's questions. Based on these findings, the nurse should report that the client has which problem?
delirium
A charge nurse is completing client assignments on a neurologic unit. One full-time nurse from the unit, two floating nurses, and one agency nurse are present for the shift. The charge nurse should assign the unit's full-time nurse to care for the client who
has a craniotomy 24 hours earlier for a brain hemorrhage
A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
heparin sodium
A client with a diagnosis of alcohol intoxication and suspected alcohol dependence is admitted to the psychiatric unit. Other assessment findings include an enlarged liver; jaundice; lethargy; and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what should the first priority be?
instituting seizure precautions, obtaining vitals frequently, and recording fluid intake and output
A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should
keep the affected leg level or slightly dependent.
A client with epilepsy is having a seizure. During the active seizure phase, the nurse should
place the client on their side, remove dangerous objects, and protect their head
The healthcare provider prescribes aspirin 325 mg by mouth each day for a client diagnosed with a transient ischemic attack (TIA). During education, how should the nurse identify the purpose of this medication?
reduces the chance of blood clot formation
A nurse is preparing a teaching plan for a client with thromboangiitis obliterans (Buerger's disease). Which goal is the highest priority for this client?
stop smoking
Which is not a typical clinical manifestation of multiple sclerosis (MS)?
sudden bursts of energy
Which goal is the most realistic for a client diagnosed with Parkinson's disease?
to maintain optimal body function
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. What information should the nurse include in the teaching plan?
"Keep active, use tress reduction strategies, and avoid fatigue."
An adolescent girl with a seizure disorder controlled with phenytoin and carbamazepine asks the nurse about getting married and having children. Which response by the nurse would be mostappropriate?
"When you decide to have children, talk to the health care provider about changing your medications"
A nurse has a client with multiple sclerosis who, after attending a meeting with the Multiple Sclerosis Society, states complementary therapies would work better. What is the best response by the nurse?
"You have a right to search out options and make decisions to help manage your symptoms.Share with me what you learned."
A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?
Avoid stimulants and alcohol for 24-48 hours before the test.
A client is receiving a transfusion of packed red blood cells. What should the nurse do to safely administer the blood?
Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction.
A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by:
showing the location of the obstruction and the collateral circulation
