NRS112 Quiz 4
A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? -The P wave falls before the QRS complex -The T wave is in the inverted position -The P-R interval measures 0.22 seconds -The QRS duration is 0.20 seconds.
The P wave falls before the QRS complex (The nurse should recognize that in normal sinus rhythm the P wave, representing atrial depolarization, falls before the QRS wave.)
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? -Jugular Venous Distention -Abdominal Distention -Dependent Edema -Hacking Cough
Hacking Cough (A hacking cough is a manifestation of left-sided heart failure that occurs due to pulmonary congestion.)
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? -Establish the ability to communicate effectively. -Compensate for the loss of depth perception -Learn to control impulsive behavior -Improve left-side motor function
Establish the ability to communicate effectively. (A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.)
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about the action to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching? ="Insert a padded tongue blade into the client's mouth." -"Restrain the Client" -"Place the client on his back" -"Move objects away from the client."
"Move objects away from the client." (The nurse should instruct the family to move objects away from the client to reduce the risk of injury to the client.)
A nurse is teaching a client who has a new prescription for sumatriptan tablets to treat migraine headaches. Which of the following instructions should the nurse include? -"Take daily to prevent headaches." -"Chew tablet well before swallowing." -"Report swelling of the eyelids after dosage." -"Repeat dose in 1 hour for unrelieved headache."
"Report swelling of the eyelids after dosage." (The client should report swelling of eyelids and lips to provider, which can indicate an allergic reaction to this medication.)
A nurse is preparing to administer clonazepam 1.5mg PO in 3 equally divided doses ever 8 hr for a client who has seizures. The amount available is clonazepam 0.5mg tablets. How many tablets should the nurse administer per dose? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
1 Tablet
A nurse is caring for a client who has heart failure and reports increased shortness of breath. Which of the following actions should the nurse take first? -Auscultate lung sounds -Check oxygen saturation -Obtain the client's weight -Assist the client into high-Fowler's position
Assist the client into high-Fowler's position (Using the ABC priority approach to client care, the first action to take is to assist the client into high-Fowler's position. This will decrease venous return to the heart (preload) and help relieve lung congestion.)
A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? -Encourage brief exercise before meals to promote appetite. -Place food in the affected side of the mouth. -Encourage the client to take small bites. -Place the client with the head back to facilitate swallowing.
Encourage the client to take small bites. (The family members should encourage the client to take small bites and chew food thoroughly in order to prevent choking.)
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? -Gradual onset of several hours -Manifestations preceded by a severe headache -Maintains consciousness -History of neurological deficits lasting less than 1 hr.
Manifestations preceded by a severe headache (A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke.)
A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse take? -Obtain IV access -Keep the lights on while the client is sleeping -Place the client's bed in the highest position -keep a padded tongue blade available at the client's bedside
Obtain IV access (The nurse should obtain IV access as a precaution so the client can receive IV medications in the event of a seizure.)
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? -Check the client's blood pressure -Auscultate heat tones -Perform a 12-lead ECG -Determine if the pain radiates to the left arm
Perform a 12-lead ECG (The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction.)
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions by the nurse is the priority? -Place a pillow under the child's head -Position the child side-lying -Loosen restrictive clothing -Clear the area of hazards
Position the child side-lying (This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.)
A nurse in the emergency department is caring for a client who is experiencing manifestations of a MI. Which of the following laboratory tests should the nurse expect the provider to prescribe? -Troponin -Creatinine kinase (CK) -Brain natriuretic peptide -C-reactive protein
Troponin (Troponin is released by the myocardial muscle when injury occurs. Troponin is not present in the body at any other time, making it very specific to cardiac injury. Troponin levels in the blood can rise within 2 to 3 hr of the onset of an MI. This allows for a quick diagnosis and is the gold standard when treating clients who have suspected MI.)
A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? -poor impulse control -unable to discriminate words and letters -deficits in the right visual field -motor retardation
poor impulse control (A client who had a stroke involving the right cerebral hemisphere is likely to have personality changes, which can include impulsiveness, confabulation, and poor judgment.)
a nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. which of the following cardiac enzymes would confirm the infarction occurred 14 days ago? - CK-MB - troponin I - troponin T - myoglobin
troponin T (Troponin T level will be evident 10-14 days after an MI)
A nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? -"These tests help determine the degree of damage to the heart tissues." -"Cardiac enzymes will identify the location of the MI." "These tests will enable the provider to determine the heart structure and mobility of the heart valves." -"Cardiac enzymes assistance in diagnosing the presence of pulmonary congestion."
"These tests help determine the degree of damage to the heart tissues." (Cardiac enzyme studies are obtained because the degree of enzyme elevation reflects the degree of damage to the myocardium. The enzymes most commonly measured are CPK and troponin. These enzymes have a characteristic rise and fall pattern after an MI. It may take 4 hr or more after the onset of manifestations for the test to become abnormal and up to 24 hr for the level to peak. Eventually, the levels in the blood fall back to normal. Consequently, serial blood tests must be taken from the client to document and evaluate enzyme levels.)
A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? -Ventricular Depolarization -Slow repolarization of ventricular Purkinje fibers -Atrial depolarization -Early ventricular repolarization
Atrial depolarization (The P wave reflects atrial depolarization, typically initiated in the sinoatrial node.)
For each of the following findings in the clients medical record, click to specify if they are consistent with angina or a MI. Each finding may support more than one disease process. -Treadmill Stress Test -Provider Consult -12 Lead EKG report -Client's initial report of manifestations -Result of Nitroglycerin Therapy
The 12 lead EKG report indicates that ST depression and T-wave inversion can be consistent with both angina and a non-ST segment myocardial infarction (MI). The result of the client's nitroglycerin therapy is consistent with angina. The discomfort of an MI is relieved only by opioids. The client's initial report of manifestations can be consistent with both angina and an MI. Not all clients experience chest pain when having an MI. The provider's prescription of a treadmill stress test for the client is consistent with angina. A client who has an MI will require a reperfusion intervention such as thrombolytic therapy, angioplasty, or coronary bypass surgery. A cardiology consult is consistent with both angina and an MI. Management of the client's cardiovascular health will need to be directed by a cardiologist.
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first? (SATA) ~Loosen restrictive clothing ~Insert a bit stick into the client's mouth ~Place the client into a supine position ~Place a pillow under the client's head ~Apply restraints
~Loosen restrictive clothing ~Place a pillow under the client's head (Loosen restrictive clothing is correct. Loosening clothing, such as a belt or collar, aids in respiratory and abdominal expansion. The client should not be restrained. Insert a bite stick into the client's mouth is incorrect. A bite stick or padded tongue blade can cause an obstruction in the client's airway or further injury if teeth are broken as a result of the jaw clamping down on the bite stick. Place the client into a supine position is incorrect. If it is possible to do without causing injury to the client, the nurse should assist the client who is having a seizure into a lateral position. This position assists with the drainage of saliva and mucus, preventing aspiration, and allows the tongue to fall forward, preventing airway obstruction. Place a pillow under the client's head is correct. The nurse should place a pillow or rolled blanket under the client's head to protect the head from injury. Apply restraints is incorrect. The nurse should not restrict movement of a client who is having a seizure. Instead, the nurse should guide the client's movements to prevent injury and, if possible, assist the client into a lateral position.)
A nurse in an emergency department is assessing a client who is having a suspected MI. Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (SATA) ~Orthopnea ~Headache ~Nausea ~Tachycardia ~Diaphoresis
~Nausea ~Tachycardia ~Diaphoresis (Orthopnea is incorrect. Orthopnea is a manifestation of heart failure, which can develop from an MI but is not a common manifestation of an acute MI. A client experiencing an MI typically manifests dyspnea. Headache is incorrect. Chest pain and sometimes jaw, back, and shoulder pain are manifestations of an acute MI. Nausea is correct. Nausea and vomiting are manifestations of an acute MI. Tachycardia is correct. Tachycardia and dysrhythmias are manifestations of an acute MI. Tachycardia can also occur as a result of the client's anxiety. Diaphoresis is correct. Profuse sweating and anxiety are manifestations of an acute MI.)
