NRSG 305 Practice Questions Exam 4
Which maternal factor contributes to an infant having macrosomia, hypoglycemia, and hyperbilirubinemia? Maternal diabetes Maternal nutrition Fetal gene disorder Fetal chromosome disorder
Maternal diabetes
The nurse explaining the causes of congenital hydrocephalus to the mother of a child born with hydrocephalus includes: Bacterial infection Aqueductal stenosis Tumor Hemorrhage
Aqueductal stenosis
The nurse is working with a client who has been diagnosed with recurring migraine headaches. Which advice by the nurse is most appropriate? "Many people find that maintaining regular eating and sleeping habits is beneficial." "It's likely in your best interest to move to a rural setting and explore getting a less stressful job." "Migraines are poorly understood and are generally considered unavoidable, so always have your medication with you." "Migraine headaches usually respond poorly to medication, so I can help you explore nonpharmacologic options."
"Many people find that maintaining regular eating and sleeping habits is beneficial."
Which symptom indicates the next stage of a fever after a prodrome? A flush A chill Defervescence Prodrome
A chill
Which criterion about insulin would prompt a diagnosis of type 1 diabetes? Large amounts of insulin secreted Small amounts of insulin secreted Insulin not efficiently used Complete failure of insulin secretion
Complete failure of insulin secretion
There are several types of brain injuries that can occur. What are the primary (or direct) brain injuries? Select all that apply. Focal lesions of laceration Contusion Hypoxic Diffuse axonal Hemorrhage
Focal lesions of laceration Contusion Diffuse axonal Hemorrhage
The nurse is caring for a client who received regular insulin at 7 am. Four hours later the nurse finds the client diaphoretic, cool, and clammy. Which of these interventions is the priority? Bathe the client with tepid water. Give the client a concentrated carbohydrate. Repeat the dose of insulin. Place the client in the supine position.
Give the client a concentrated carbohydrate.
When a peripheral nerve is irritated enough, it becomes hypersensitive to the noxious stimuli, which results in increased painfulness or hyperalgesia. Health care professionals recognize both primary and secondary forms of hyperalgesia. What is primary hyperalgesia? Pain that occurs in the tissue surrounding an injury Pain sensitivity that lasts longer than 1 week Pain sensitivity that occurs in the viscera Pain sensitivity that occurs directly in damaged tissues
Pain sensitivity that occurs directly in damaged tissues
A client has started having uncontrolled seizures that are not responding to usual medications. Nurses working with the client must pay special attention to which priority aspects of this client's care? Assessment of: ECG for arrhythmias Urine output and continence Ability to grasp hands and squeeze on command Respiratory status and oxygen saturation
Respiratory status and oxygen saturation
A client suffering a thrombotic stroke is brought into the emergency department by ambulance and the health care team is preparing to administer a synthetic tissue plasminogen activator for which purpose? Thrombolysis Thrombogenesis Hemolysis Hemostasis
Thrombolysis
The most common cause of an ischemic stroke is which of the following? Intracerebral arterial vasculitis Cardiogenic embolus Thrombosis Vasospasm
Thrombosis
Global or diffuse brain injury is manifested by changes in the level of consciousness. True False
True
Myasthenia gravis is characterized by muscle weakness caused by antibody-mediated loss of which physiologic function? Periorbital muscles Thymus gland cells Skeletal muscle fibers Acetylcholine receptors
Acetylcholine receptors
Which resident of a long-term facility is exhibiting clinical manifestations of hypothyroidism? An 80-year-old woman who has uncharacteristically lost her appetite of late and often complains of feeling cold A 90-year-old woman with a history of atrial fibrillation whose dysrhythmia has recently become more severe An 88-year-old man with a history of Alzheimer disease who has become increasingly agitated and is wandering around the facility more frequently A 91-year-old man with a chronic venous ulcer and a sacral ulcer who has developed sepsis
An 80-year-old woman who has uncharacteristically lost her appetite of late and often complains of feeling cold
A client has just been diagnosed with multiple sclerosis (MS). The nurse recognizes that the client's condition is a result of: An immune-mediated response that is caused by the demyelinization of the myelin sheath of the white matter of the brain, spinal cord, and optic nerve Degenerative changes in the musculoskeletal system Circulating antibodies attacking the postsynaptic acetylcholine levels Degeneration of the lower cell bodies of the lower motor neurons in the gray matter
An immune-mediated response that is caused by the demyelinization of the myelin sheath of the white matter of the brain, spinal cord, and optic nerve
A client reports general malaise and has a temperature is 103.8°F (39.9°C). What is the rationale for administering a prescribed aspirin, an antipyretic, to this client? Temperatures in excess of 99.5°F (37.5°C) can result in seizure activity. Lower temperatures inhibit the protein synthesis of bacteria. Antipyretics protect vulnerable organs, such as the brain, from extreme temperature elevation. Most antipyretics have been shown to have little effect on core temperature but alleviate discomforts.
Antipyretics protect vulnerable organs, such as the brain, from extreme temperature
What medication teaching should be done for a woman of childbearing age with a seizure disorder? Antiseizure drugs increase the risk for congenital abnormalities. Antiseizure drugs do not interact with oral contraceptives. Some antiseizure drugs can interfere with vitamin K metabolism. All women of childbearing age should be advised to take a vitamin C supplement.
Antiseizure drugs increase the risk for congenital abnormalities.
Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction? Apply cooling blanket Give client a warm bath Lower the room temperature Remove the client's blankets
Apply cooling blanket
A client with a spinal cord injury at T8 would likely retain normal motor and somatosensory function of her: Arms Bowels Bladder Perineal musculature
Arms
A client is to have a serum thyroxine and thyroid stimulating laboratory test performed to assess the baseline status of the hypothalamic-pituitary target cell hormones. When educating the client about the laboratory tests, when would the nurse inform him the test should be obtained? Before 0800 After 0900 Prior to midnight At noon
Before 0800
When conducting a health assessment that focuses on the pain experienced by an older client diagnosed with early dementia, the nurse will pay particular attention to which of the following? Behavioral signs of pain demonstrated by the client The client's verbal perception of pain Cultural beliefs held by the client regarding the cause of pain The client's comfort level regarding the discussion of pain
Behavioral signs of pain demonstrated by the client
The nurse and nursing student are caring for a client undergoing a severe stressor with release of epinephrine into the bloodstream. The nurse teaches the student that epinephrine will cause which effect on blood glucose levels? Blood glucose will elevate. Hypoglycemia will occur. An unusable form of glucose will be released. Gluconeogenesis will be suppressed.
Blood glucose will elevate.
The diabetes nurse educator is teaching a community education class for new diabetics. Which of these does the nurse include in the discussion of signs and symptoms of hyperglycemia? Select all that apply. Anorexia Blurred vision Weight loss Fine moist skin Thirst
Blurred vision Weight loss Thirst
Which cardinal assessment finding would lead the nurse to suspect a client has developed Parkinson disease? Hypotonia Bradykinesia Paresthesia Lack of sweating
Bradykinesia
When caring for the client with diabetic ketoacidosis, the nurse recognizes that fatty acids and ketones may be used for energy by most organs. Which organ does the nurse recognize is reliant on glucose as the major energy source? Heart Lungs Spleen Brain
Brain
Nonshivering thermogenesis occurs in which of the following to help the newborn infant fight hypothermia? Brown fat Adipose tissue Subcutaneous tissue Epidermis
Brown fat
The health care provider is concerned that a client may be at risk for problems with cerebral blood flow. The most important data to assess would be: Decreased level of oxygen Decreased level of PCO2 Decreased level of carbon dioxide Decreased hydrogen ions
Decreased level of oxygen
Regarding the pathophysiology of Parkinson disease, which statement is true? Degeneration of the nigrostriatal dopamine neurons occurs. The dopamine receptors increase from an alteration in neuronal basal ganglia. Failure of the cerebral cortex interferes with the use of acetylcholine. Acetylcholine levels rise and inhibit voluntary movement.
Degeneration of the nigrostriatal dopamine neurons occurs.
Which statement best describes the pathophysiology of Parkinson disease? Degeneration of the nigrostriatal dopamine system Increase in the number of dopamine receptors by an alternate basal ganglion Failure of the cerebral cortex, which does not allow the use of acetylcholine Rise in acetylcholine levels, causing an inhibition of voluntary movement
Degeneration of the nigrostriatal dopamine system
The nurse is preparing a client for a test that will measure negative feedback suppression of ACTH. Which medication will the nurse administer in conjunction for this test? Dexamethasone ACTH Dextrose 50% A normal saline bolus dose of 100 mL
Dexamethasone
A client's recent diagnosis of Parkinson disease has prompted the care provider to promptly begin pharmacologic therapy. The drugs prescribed will likely influence the client's levels of which substance? Dopamine Acetylcholine Serotonin Adenosine
Dopamine
A child is being seen in the emergency department (ED) after ingesting crayons with lead in them. He is disoriented and having seizures. The provider suspects he has which of the following? Encephalitis Viral meningitis Meningioma Bacterial meningitis
Encephalitis
An individual experiencing spinal cord damage (SCD) is at high risk for developing deep vein thrombosis (DVT) and pulmonary emboli (PE) due to which pathophysiologic cause? Select all that apply. Impaired mobility Impaired vasomotor tone Hypercoagulation of blood Impaired pain perception Stasis of blood flow
Impaired mobility Impaired vasomotor tone Hypercoagulation of blood Stasis of blood flow
A client who is being treated for chronic low back pain is using a TENS unit for relief of pain. The nurse is aware that the use of this device is considered what type of pain relief? Stimulus-induced analgesia Distraction A physical agent Biofeedback
Stimulus-induced analgesia
A client who is being seen in the outpatient clinic reports a single episode of unilateral arm and leg weakness and blurred vision that lasted approximately 45 minutes. The client is most likely experiencing: Transient ischemic attack (TIA) Cardiogenic embolic stroke Thrombotic stroke Lacunar infarct
Transient ischemic attack (TIA)
Which client will the nurse be assessing in relation to problems with thermoregulation? 66-year-old client with damage to the hypothalamus secondary to a cerebral vascular accident. 22-year-old client with damage to the cerebellum secondary to a motorcycle accident. 68-year-old client with end-stage neurosyphilis. 45-year-old client with a T8 fracture secondary to a diving accident.
66-year-old client with damage to the hypothalamus secondary to a cerebral vascular
Which complication of acromegaly can be life threatening? Cardiac structures increase in size Splayed teeth result in impaired chewing Vertebral changes result in kyphosis Bone overgrowth causes arthralgias
Cardiac structures increase in size
Peripheral nerve disorders are not uncommon. What is an example of a fairly common mononeuropathy? Guillain-Barré syndrome Carpal tunnel syndrome Myasthenia gravis Phalen maneuver
Carpal tunnel syndrome
Which intracranial volume is most capable of compensating for increasing intracranial pressure? Brain cell tissue Intravascular blood Surface sulci fluid Cerebrospinal fluid
Cerebrospinal fluid
Disorders of the pyramidal tracts, such as a stroke, are characterized by which physical finding? Hypotonia Muscle rigidity Paralysis Involuntary movements
Paralysis
Nystagmus due to cerebellar dysfunction would most likely interfere with which activity? Walking Speech Fine motor skills Reading
Reading
Which complication of spinal cord injury is the most preventable in a paraplegic client? Skin breakdown Muscle atrophy Deep vein thrombosis Autonomic dysreflexia
Skin breakdown
A client with type 1 diabetes mellitus wishes to stop taking insulin injections. What option is appropriate? Using an insulin infusion pump Taking the herb chromium picolinate Increasing daily aerobic activity Taking metformin
Using an insulin infusion pump
A recovery room nurse monitoring a client for adverse effects of cold cardioplegia assesses for: Ventricular dysrhythmia Postoperative anxiety Increased intercranial pressure Postoperative migraine
Ventricular dysrhythmia
Intracranial aneurysms that rupture cause subarachnoid hemorrhage in the client. How is the diagnosis of intracranial aneurysms and subarachnoid hemorrhage made? CT scan MRI Loss of cranial nerve reflexes Venography
CT scan
What will conduct injurious stimuli to alert the body to potential damage? Nociceptors Thermoreceptors Proprioceptors Odorant
Nociceptors
The nurse learns that different types of headaches respond to different therapies. Which headache is most responsive to nonpharmacologic therapy? Tension Cluster Migraine Sinus
Tension
A client is managing his type 2 diabetes with exercise and diet. He has a fasting blood sugar level (FBS) of 80 mg/dL (4.44 mmol/L) and a hemoglobin A1C of 5% (.05). Based on these findings, which of the following can the nurse assume? The client is achieving normal glycemic control. The client needs to modify his diet related to the low readings. The client is at risk for developing hyperglycemia. The client is at risk for an insulin reaction.
The client is achieving normal glycemic control.
A client has recently been diagnosed with chronic back pain that requires the daily use of hydromorphone, an opioid analgesic. For the first few weeks, the client achieved relief with 4 mg every 6 hours. However, the client now requires 6 mg doses to achieve the same effect. How should the nurse best interpret this phenomenon? The client is exhibiting the early signs of opioid addiction The client is developing opioid tolerance, which is expected The client's medication should be replaced with nonpharmacologic interventions The opioid should likely be replaced with a nonsteroidal anti-inflammatory drug (NSAID)
The client is developing opioid tolerance, which is expected
The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should: assess the client for additional signs/symptoms of increased intracranial pressure. contact the physician. instruct the spouse not to let the client fall asleep until the physician has assessed the client. prepare the client for EEG testing.
assess the client for additional signs/symptoms of increased intracranial pressure.
A client has developed noncommunicating hydrocephalus and asks the nurse what may have caused this to occur. How will the nurse respond? obstruction preventing the flow of cerebrospinal fluid (CSF) increased fluid absorption leading to cerebral edema decreased cerebrospinal fluid (CSF) flow in the ventricular system increased reabsorption of cerebrospinal fluid (CSF)
obstruction preventing the flow of cerebrospinal fluid (CSF)
A client with severe hypoglycemia is unconscious. Which method of providing glucose should not be used for this client? dextrose IV glucose gel in the buccal pocket orange juice orally glucagon IM
orange juice orally
The most common cause of ischemic stroke is: thrombosis. arterial vasculitis. vasospasms. cryptogenesis.
thrombosis.
The nurse has just completed an assessment on a client admitted with Guillain-Barré syndrome. The nurse determines that a priority of care will be: ventilatory assessment and support. emotional support. administration of antibiotics. feeding the client.
ventilatory assessment and support.
What can the nurse tell a client about antipyretic drugs during fever? "They are not recommended." "They usually have little effect." "Antipyretics help to protect the body." "Antipyretics are ineffective in most cases."
"Antipyretics help to protect the body."
An older adult tells the nurse, "My friend just developed shingles and has a lot of pain. Is there a way for me to protect myself from it?" How should the nurse respond? "Avoid children and people with shingles." "Ask your healthcare provider about a herpes zoster vaccine." "Use antiviral drugs as soon as you are exposed." "Apply a topical anesthetic agent."
"Ask your healthcare provider about a herpes zoster vaccine."
A client diagnosed with type 2 diabetes has been instructed about managing his condition with diet. Which statements by the client indicate a need for additional education? Select all that apply. "I must avoid all candies and cookies, but can eat unlimited amounts of pasta and breads." "I can drink 8 to 10 glasses of water daily without concern for calories." "I need to limit the amount of foods that I eat that contain trans fats." "I need to avoid adding salt to my foods." "I need to carefully limit my protein consumption."
"I must avoid all candies and cookies, but can eat unlimited amounts of pasta and breads." "I need to carefully limit my protein consumption."
When providing nutrition education to the client with diabetes, the nurse should include which statement regarding fat intake? "People with diabetes should not consume fats." "If you have diabetes, avoiding saturated fats is important." "When diabetes is present, 40% of calories may be from fat." "Individuals with type 2 diabetes may consume more fat calories than those with type 1 diabetes."
"If you have diabetes, avoiding saturated fats is important."
A client arrives in the clinic and informs the nurse that he is having pain in the left knee that has lasted for several weeks. The physician orders an x-ray of the left hip and knee. The client tells the nurse that the pain is in the knee, not the hip. What is the best response by the nurse? "The physician must have misunderstood what you were saying. We will change the order." "The pain you are having may be referred pain, which can cause the pain in the knee resulting from a hip problem." "The pain you are having is most likely caused by a disturbance in your nerve transmission." "You only think that the pain is in the knee when it really is in your hip."
"The pain you are having may be referred pain, which can cause the pain in the knee resulting from a hip problem."
A client with a new diagnosis of type 2 diabetes mellitus states, "I am really worried that I might need to take injections. Is there something I can do to avoid that?" What is the best response by the nurse? "If you exercise weekly, you won't need injections." "You could regulate your diet, exercise regularly, and lose weight." "Diabetes management is complicated; you can't avoid injections." "A support group could help you cope with stress and learn helpful tips."
"You could regulate your diet, exercise regularly, and lose weight."
A nurse assessing an older adult 3 hours postoperative notes guarding, grimacing, and stiff body movement when changing positions. The client denies feeling pain. Which response will help the nurse best manage this client's pain? "You seem to be uncomfortable. Pain is common with surgery. I can bring you pain medication." "You just had surgery. Are you sure you are not having any pain?" "I can come back in an hour to see if you are having any pain then." "Are you afraid of becoming addicted if I give you any pain medication?"
"You seem to be uncomfortable. Pain is common with surgery. I can bring you pain medication."
When educating a client with possible glucocorticoid dysfunction, the nurse will explain that the CRH controls the release of ACTH. The best time to perform the blood test to measure peak ACTH levels would be: 06:00 to 08:00 AM 10:00 AM to noon 04:00 to 6:00 PM 09:00 to 11:00 PM
06:00 to 08:00 AM
The nurse evaluates which body temperatures to be outside the normal range? Select all that apply. 97.5°F (36.4°C) 100.4°F (37.8°C) 96.6°F (35.9°C) 99.0°F (37.2°C)
100.4°F (37.8°C) 96.6°F (35.9°C)
A nurse is working at the medical booth at a marathon on a hot summer day. Which individual is at greatest risk for hyperthermia? 25-year-old running in the marathon 56-year-old with a history of a myocardial infarction walking the marathon 83-year-old spectator with congestive heart failure 13-year-old running the marathon
83-year-old spectator with congestive heart failure
The nurse is reviewing assessment data and determines which client is at highest risk for developing type 2 diabetes? A 45-year-old obese female with a sedentary lifestyle A 10-year-old male whose grandmother has type 2 diabetes A 40-year-old male who has liver disease due to hepatitis A 60-year-old female with a history of gestational diabetes
A 45-year-old obese female with a sedentary lifestyle
A client is diagnosed with hyperthyroidism and is exhibiting weight loss, diarrhea, and tachycardia. What does the nurse understand that these clinical manifestations are related to? A decrease in oxygen consumption A decrease in the level of glucose A hypermetabolic state A decrease in sympathetic nervous system activity
A hypermetabolic state
A client with small cell carcinoma lung cancer may secrete an excess of which hormone, causing an ectopic form of Cushing syndrome due to a nonpituitary tumor? GH TSH DHEA ACTH
ACTH
One of the earliest signs of Cushing syndrome is the loss of variable diurnal secretion of cortisol-releasing hormone (CRH) and: GH TSH DHEA ACTH
ACTH
Which principle best explains symptoms of amyotrophic lateral sclerosis (ALS), including dysphagia, muscle weakness and spasticity, and dysphonia? ALS is caused by disruption to the cerebellum. ALS is caused by lack of dopamine in the body. ALS is caused by muscular necrosis. ALS is caused by both an upper motor neuron and lower motor neuron disturbance.
ALS is caused by both an upper motor neuron and lower motor neuron disturbance.
The nurse is assessing a male client and finds abnormally large hands and feet, a bulbous nose, and a broad face with a protruding jaw. Based on these findings, which endocrine abnormality is most likely the cause for these physical changes? Acromegaly Hyperthyroidism Myxedema Cushing syndrome
Acromegaly
A client fell from a ladder and broke his ankle and is being seen in the emergency department for severe ankle pain with swelling and limited range of motion. What type of pain does the nurse recognize the client is experiencing? Chronic pain Subacute pain Acute pain Visceral pain
Acute pain
The nurse is caring for a client who has returned from surgery after having a colon resection. What is the best method for the nurse to use when administering an opioid for pain in order to optimize pain control? Administer the opioid each time the client asks for it. Administer the opioid preemptively and before pain becomes extreme. Administer the opioid if the client is becoming restless. If the client is asleep, wait until she awakens to administer an opioid, because sleeping clients are not in pain.
Administer the opioid preemptively and before pain becomes extreme.
A 60-year-old male is being treated for significant denervation and muscle fiber atrophy. His movements are still smooth and he has no cognitive defects. Which likely diagnosis is associated with these clinical manifestations? Multiple sclerosis, an upper motor neuron (UMN) disorder Spinal muscular atrophy, a lower motor neuron (LMN) disorder Parkinson disease, a disorder of basal ganglia Amyotrophic lateral sclerosis, a mixed UMN/LMN disorder
Amyotrophic lateral sclerosis, a mixed UMN/LMN disorder
A nurse is teaching a client newly diagnosed with a seizure disorder. Which statement is most important for the nurse to provide regarding antiepileptic medications? Antiepileptic medications should never be discontinued abruptly. All antiepileptic medications should be taken with food. Children can build up a tolerance to the medication quickly. Pregnant women should reduce the dose of medication or discontinue until after delivery.
Antiepileptic medications should never be discontinued abruptly.
The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first? Assess for other signs/symptoms of increased intracranial pressure. Assess for signs/symptoms of cerebrovascular accident (stroke). Contact physician for anti-nausea medication orders. Document the finding as it is an expected symptom.
Assess for other signs/symptoms of increased intracranial pressure.
A client has sustained a severe, diffuse brain injury that resulted in seriously compromised brain function. The client is at greatest risk for: Brain death Paraplegia Confusion Amnesia
Brain death
What will the nurse teach a client with trigeminal neuralgia about the condition? Carbamazepine is a first-line treatment. Surgery will relieve the condition. It is good to spend time alone every day. Avoid eating if it triggers the pain.
Carbamazepine is a first-line treatment.
A client with a rising temperature is pale and has begun to shiver. The nurse reports that the client is in which phase of fever development? Prodrome Chill Flush Defervescence
Chill
A 23-year-old man is admitted to the hospital. He is experiencing polyphagia, polyuria, and polydipsia. He states that the condition has come on very suddenly. This client is likely to require what treatment? Exogenous insulin injections Sulfonylureas Biguanides Meglitinides
Exogenous insulin injections
Bradykinesia occurring in Parkinson disease places the Parkinson's client most at risk for: Weight loss Falls and injury Emotional dysfunction Incontinence
Falls and injury
A sudden, traumatic, complete transection of the spinal cord results in what type of injury below the site? Flaccid paralysis Vasoconstriction Deep visceral pain 3+ tendon reflexes
Flaccid paralysis
Type 1A diabetes is now considered an autoimmune disorder. What factors are considered necessary for type 1A diabetes to occur? Genetic predisposition, environmental triggering event, and a T-lymphocyte-mediated hypersensitivity reaction against some beta-cell antigen Genetic predisposition, physiologic triggering event, allergic reaction to pancreatic alpha cells Diabetogenic gene from both parents, physiologic triggering event, and an allergic reaction to pancreatic delta cells Diabetogenic gene from both parents, environmental triggering event, and a B-lymphocyte reaction to alpha cell antigens
Genetic predisposition, environmental triggering event, and a T-lymphocyte-mediated hypersensitivity reaction against some beta-cell antigen
A nurse is preparing for a course in cardiopulmonary resuscitation (CPR) and realizes that ventricular fibrillation quickly disrupts blood flow to the brain that causes which result in a matter of seconds? Regional ischemia Global hypoxemia Global ischemia Global hypoxia
Global ischemia
A 62-year-old man who is overweight has just been diagnosed with type 2 diabetes. The nurse educator is instructing him in the ways his diabetes can be controlled. The nurse should initially prioritize which action? Assisting the client with the appropriate choice of oral antihyperglycemics. Educating the client about the risks and management of hypoglycemia. Helping the client make meaningful changes to his diet and activity level. Teaching the client about the action and safe administration of insulin.
Helping the client make meaningful changes to his diet and activity level.
A nurse is assessing a client with symptoms of botulism. The nurse will question the client regarding ingestion of which food? Dairy products Unrefrigerated meat Home-grown and canned vegetables Fresh fish
Home-grown and canned vegetables
With which activity would a client experiencing astereognosis need help? Chewing and swallowing food Maintaining bladder continence Identifying an object by touch Recognizing faces
Identifying an object by touch
A client comes to the clinic with fatigue and muscle weakness. The client also states she has been having diarrhea. The nurse observes the skin of the client has a bronze tone and when asked, the client says she has not had any sun exposure. The mucous membranes of the gums are bluish-black. When reviewing laboratory results from this client, what does the nurse anticipate seeing? Elevated WBC count Increased levels of ACTH Increase in sedimentation rate Positive C-reactive protein
Increased levels of ACTH
During an intense aerobic activity, how does the body regulate temperature during a well-trained athlete's workout? Increasing heat loss by producing sweat Shunting blood flow to the vital organs and away from the skin Producing sweat that is high in sodium concentration Constricting the blood vessels of the skin
Increasing heat loss by producing sweat
In describing the ideal analgesic, what factors would be included? Select all that apply. Inexpensive Have minimal adverse effects Effective Addictive Decrease the level of consciousness
Inexpensive Have minimal adverse effects Effective
Select the most appropriate intervention for the nurse to teach a client diagnosed with distal symmetric neuropathy related to diabetes. Inspect the feet for blisters daily Rotate insulin injection sites once a week Wear comfortable, open-toed shoes Decrease daily walking activity
Inspect the feet for blisters daily
Which neuron connects sensory and motor neurons? Afferent neurons Efferent neurons Cranial nerves Interneurons
Interneurons
A client's emergency magnetic resonance imaging (MRI) has been examined by the physician and tissue plasminogen activator (tPA) has been administered to the client. What was this client's most likely diagnosis? Status epilepticus Subarachnoid hemorrhage Ischemic stroke Encephalitis
Ischemic stroke
The nurse reading a client's lumbar puncture results notifies the physician of findings consistent with meningitis when which sign/symptom is noted? Large number of polymorphonuclear neutrophils Clear cerebrospinal fluid Decreased protein count Increased glucose
Large number of polymorphonuclear neutrophils
Which factor contributes to an infant developing macrosomia (large body size)? Maternal diabetes Maternal nutrition Fetal gene disorder Fetal chromosome disorder
Maternal diabetes
Restoration of the integrity of myelin sheaths would likely result in a slowing or stopping of the progression of: Amyotrophic lateral sclerosis (ALS) Multiple sclerosis (MS) Duchenne muscular dystrophy (DMD) Paralysis caused by Clostridium botulinum
Multiple sclerosis (MS)
The nurse is caring for an older adult client with hemiplegia following a stroke. While planning the client's care, the nurse knows the client is at risk for developing which condition? Muscle atrophy Muscular dystrophy Involuntary movements Pseudohypertrophy
Muscle atrophy
A client who has experienced a spinal cord injury still has use of the arms but has impaired motor and sensory function of the trunk, legs, and pelvic organs. Which term best describes how this injury is classified? Paraplegia Tetraplegia Quadriplegia Brown-Séquard syndrome
Paraplegia
A client reports feeling a tingling sensation in the last two fingers of one hand after hitting the inner surface of the elbow on a desk. What is the cause of this symptom? Paresthesia from temporary nerve compression Hypersensitivity reaction to nerve injury Hyperpathia from localized ischemia Hypoesthesia from an inherited response
Paresthesia from temporary nerve compression
Which disease can result in symptoms that can occur when a brain tumor causes damage to the nigrostriatal pathway? Truncal ataxia Guillain-Barré syndrome Alzheimer disease Parkinson disease
Parkinson disease
The nurse is providing client education to a client newly diagnosed with Parkinson disease. The nurse most accurately describes the disease progression as: Parkinson's is an acute disorder that can be surgically corrected. Parkinson's is a chronic condition and treatment aims to manage symptoms. Parkinson's has no known effective treatment. Parkinson's disease, while chronic, will likely improve over time.
Parkinson's is a chronic condition and treatment aims to manage symptoms.
Select the most common symptoms of diabetes. Select all that apply. Polydipsia Polyuria Polyphagia Polyhydramnios Polycythemia
Polydipsia Polyuria Polyphagia
The parent of a toddler with Duchenne muscular dystrophy reports that the child has an increase in muscle size but a decrease in strength. The nurse documents this using which medical term? Pseudohypertrophy Fasciculations Dysdiadochokinesia Chorea
Pseudohypertrophy
A nurse caring for a client with multiple sclerosis notes that the client has mood swings. Which cause can best explain this? Depression over new diagnosis A side effect of treatment Psychological manifestation due to involvement of white matter of cerebral cortex Likely a preexisting mental illness
Psychological manifestation due to involvement of white matter of cerebral cortex
A client with a history of AIDS and CNS lymphoma is brought to the emergency department for a change in mental status and displaying extreme combativeness. A family member is very upset with the client's behavior. The nurse explains that these behaviors are most likely caused by which diagnosis? AIDS-associated encephalitis Recurrence of primary CNS lymphoma Onset of early dementia Decrease in intracranial pressure
Recurrence of primary CNS lymphoma
A client is experiencing chest pain that radiates to the left arm and neck. The nurse would interpret this pain as: Referred Visceral Cutaneous Somatic
Referred
The transmission of impulses at the neuromuscular junction is mediated by which action? Nerve stimulation of the adrenal medulla Release of neurotransmitter acetylcholine from autonomic nerve endings Connection to paraspinal ganglion chain Nerve origin in thoracolumbar spine
Release of neurotransmitter acetylcholine from autonomic nerve endings
The nursing assistant reports to the registered nurse that a client with a brain tumor has a blood pressure of 180/100 mm Hg and a pulse of 50 bpm. Which action is the correct nursing intervention? Ask the nursing assistant to obtain a glucose reading. Initiate intravenous fluids. Report to physician the client's signs of increased intracranial pressure. Contact the physician for "do not resuscitate" orders.
Report to physician the client's signs of increased intracranial pressure.
While teaching a class of nursing students about spinal cord injury, the instructor mentions that male SCI clients will be able to have a sexual response if their injury is at which level on the spinal column? T12 S1 L2 S4
S4
The nurse is studying sensory systems. She understands that signal transduction of an impulse to the thalamus for processing is accomplished by: First-order neurons Second-order neurons Third-order neurons Fourth-order neurons
Second-order neurons
A client with severe hypothyroidism is presently experiencing hypothermia. What nursing intervention is a priority in the care of this client? Active rewarming of the client to increase body temperature rapidly Placing the client on a hyperthermia blanket and using heated saline in order to induce vasodilation Slow rewarming of the client to prevent vasodilation and vascular collapse Keeping the client in a hypothermic state in order to prevent renal failure
Slow rewarming of the client to prevent vasodilation and vascular collapse
The nurse taking a report on a client coming into the emergency room plans care for a client with brain dysfunction based on which symptom? Stupor Pupils that react to light Wheezing Chest pain
Stupor
The MRA scan of a client with a suspected stroke reports ruptured berry aneurysm. The nurse plans care for a client with: Encephalitis Subarachnoid hemorrhage Lacunar infarct Thrombotic stroke
Subarachnoid hemorrhage
Which client is most likely to be susceptible to developing a neurogenic fever? Has stage 2 Alzheimer disease Sustained a head injury in a bicycle crash Became delirious after the administration of a benzodiazepine Takes a selective serotonin reuptake inhibitor (SSRI) for the treatment of depression
Sustained a head injury in a bicycle crash
A client with pneumonia is admitted with these vital signs: temperature 99.7ºF (37.6°F), pulse 80 beats/min, respirations 18/minute, and BP 120/80 mm Hg. Which set of vital signs does the nurse anticipate when the client begins to shiver and requests another blanket several hours later? T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg T 99.7ºF (37.6°C), P 86/min, R 18/min, BP 130/82 mm Hg T 98.4ºF (36.9°C), P 82/min, R 16/min, BP 106/70 mm Hg T 97.2ºF (36.2°C), P 70/min, R 12/min, BP 114/60 mmHg
T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg
A client has experienced severe head trauma during a bicycle accident. What assessment findings would suggest that the client has experienced brain death? Select all that apply. The client makes no respiratory effort in the absence of mechanical ventilation. The client exhibits no detectable brain stem reflexes. The client's pupils are unresponsive to light. The client's heart rate does not change when inotropes are administered. The client has no detectable motor responses to stimulus.
The client makes no respiratory effort in the absence of mechanical ventilation. The client exhibits no detectable brain stem reflexes. The client's pupils are unresponsive to light. The client has no detectable motor responses to stimulus.
The nurse is providing discharge instructions for a client with Graves disease who has ophthalmopathy. What should the nurse be sure to include in the instructions to decrease exacerbation of this clinical manifestation? The client should be informed that he should not be in contact with other people during the acute phase. The client should be informed that if he begins to feel symptoms getting worse, he should take an extra dose of medication. The client should be strongly encouraged not to drink any alcohol. The client should be strongly urged not to smoke.
The client should be strongly urged not to smoke.
A child is born with dwarfism to normal-sized parents. The nurse is explaining how growth hormone (GH) plays a central role in the increase in stature that characterizes childhood and adolescence. What is the first step in the growth hormone chain of events? The liver is stimulated. The hypothalamus secretes GH-releasing hormone. GH is released and circulates unbound in the plasma. Epiphyseal growth plates of long bones are influenced.
The hypothalamus secretes GH-releasing hormone.
A client comes to the clinic for evaluation of a sharp, intermittent, severe, stabbing facial pain that she describes as "like an electric shock." The pain occurs on only one side of her face. It seems to be triggered when she chews, brushes her teeth, or sometimes when she merely touches her face. Often it is accompanied by involuntary grimacing. What diagnosis is most likely? Postherpetic neuralgia Migraine headache Complex regional pain syndrome Trigeminal neuralgia
Trigeminal neuralgia
A client is brought to the emergency department and is diagnosed with an ischemic stroke confirmed by CT scan. The most important treatment for this client would be to: administer IV tissue plasminogen activator (tPA). administer analgesics for the relief of pain. monitor vital signs closely for improvement. prepare the client for emergency surgery.
administer IV tissue plasminogen activator (tPA).
The chart of a client admitted because of seizures notes that the seizure activity began simultaneously in both cerebral hemispheres. The nurse should interpret this to mean that the client experienced: generalized seizure. focal seizure without impairment of consciousness. focal seizure with impairment of consciousness. unknown type of seizure.
generalized seizure.
The parents of an infant born with hydrocephalus are concerned about the size of the baby's head. The doctors are telling them that the infant needs the surgical placement of a shunt. The nurse caring for the infant in the neonatal intensive care unit explains that placement of a shunt will: decrease the likelihood of further neurological deficits. not affect the size of the infant's head. reverse any neurologic deficits that are present. increase intracranial pressure.
decrease the likelihood of further neurological deficits.
A nurse assess an older adult client for signs and symptoms of infection. In the absence of a fever, for which will the nurse assess? Select all that apply. decreased mental status change in functional capacity fatigue weight gain depression
decreased mental status change in functional capacity fatigue
A surgical client is at greatest risk for hypothermia during a surgical procedure related to: impaired thermoregulatory mechanisms brought on by anesthesia. negligence of the anesthesiologist in regulating the body temperature. the decreased temperature of the surgical suite caused by electrical appliances. the instillation of warmed intravenous fluids that lower the core temperature.
impaired thermoregulatory mechanisms brought on by anesthesia.
A nurse notes that a client with a fever has begun to shiver. The nurse should assess for which finding? increased temperature decreased temperature hypothermia hyperthermia
increased temperature
Which pregnant woman likely faces the greatest risk of developing gestational diabetes? A client who: was diagnosed with placenta previa early in her pregnancy. is gravida five (in her fifth pregnancy). has BP of 130/85 mm Hg and pulse rate of 90 beats/minute. is morbidly obese (defined as greater than 100 pounds over ideal weight).
is morbidly obese (defined as greater than 100 pounds over ideal weight).
The parent of an infant who developed hydrocephalus while in utero is very concerned that the child will have significant intellectual dysfunction. The best response to the parent would be: "Because the skull sutures are not fused there may be no brain damage." "Infants never have symptoms from hydrocephalus." "Unfortunately, there usually is significant brain dysfunction." "The cranial sutures are fused and decrease brain damage."
"Because the skull sutures are not fused there may be no brain damage."
The critical care nurse has just admitted a client with diabetic ketoacidosis (DKA) whose blood glucose level is 877 mg/dL (48.67 mmol/L). The client's breath has a fruity odor and the client is confused. Which of these does the nurse set as the priority at this time? Administration of intravenous fluids Education related to prevention of DKA Orienting the client to the events surrounding his admission Monitoring for fever
Administration of intravenous fluids
Reflex activity involves which neurons? Afferent neurons Interneurons Efferent neurons All of the above
All of the above
When the nurse is performing a health history for a client who is being admitted for hyperthyroidism, what symptom does the client report that the nurse would find associated with this disorder? Constipation Increase in appetite Weight gain Fatigue
Increase in appetite
A febrile, 3-week-old infant is currently undergoing a diagnostic workup to determine the cause of the fever. Which statement conveys the rationale for this careful examination? The immature hypothalamus is unable to perform normal thermoregulation. Infants are susceptible to serious infections, because of their decreased immune function. Commonly used antipyretics often have no effect on the core temperature of infants. Fever in infants is often evidence of a congenital disorder rather than an infection.
Infants are susceptible to serious infections, because of their decreased immune function.
A client diagnosed with Parkinson disease is displaying the following manifestations: tremor, rigidity, and slowness of movement. The nurse would interpret these as: Normal manifestations of Parkinson disease Signs of clinical deterioration Signs of clinical improvement Manifestations of another disease process
Normal manifestations of Parkinson disease
Which structural change can contribute to mixed sensorimotor deficit? Increased brain mass and pressure Increased number of dendritic processes Polyneuropathies involving demyelination of peripheral nerves Increased number of neurons
Polyneuropathies involving demyelination of peripheral nerves
Multiple sclerosis is characterized by what type of neuron damage? Mononeuropathy Polyneuropathy Aneuropathy Transneuropathy
Polyneuropathy
Which treatment should take place immediately in a client experiencing autonomic dysreflexia? Position the client in upright position, and correct the initiating stimulus. Increase the client's blood pressure to allow for adequate perfusion. Place the client in a supine position, and increase intravenous fluids. Apply binders and support hose to shunt the blood to the main organs.
Position the client in upright position, and correct the initiating stimulus.
Which client is exhibiting headache symptoms that indicate a need for further evaluation? College student with unilateral headache after eating a chocolate bar Parent with general head pain after a night caring for an ill child Pregnant mother with drowsiness and unrelenting headache Older adult with a headache after missing the evening meal
Pregnant mother with drowsiness and unrelenting headache
A client with a diagnosis of myasthenia gravis underwent a mastectomy. The surgery was a success, but the client has gone into a myasthenic crisis on postoperative day 1. Which priority measure should the care team initiate immediately? Positioning the client to minimize hypertonia and muscle rigidity Seizure precautions with padded side rails and bed at lowest height Respiratory support and protection of the client's airway Monitoring the client for painful dyskinesias
Respiratory support and protection of the client's airway
A family brings their father to his primary care physician for a checkup. Since their last visit, they note their dad has developed a tremor in his hands and feet. He also rolls his fingers like he has a marble in his hand. The primary physician suspects the onset of Parkinson disease when he notes which abnormality in the client's gait? Slow to start walking and has difficulty when asked to "stop" suddenly Difficulty putting weight on soles of feet and tends to walk on tiptoes Hyperactive leg motions like he just can't stand still Takes large, exaggerated strides and swings arms/hands wildly
Slow to start walking and has difficulty when asked to "stop" suddenly
A client arrives in the clinic and states to the nurse, "I am tired all the time and have gained weight. My hair is so dry it is breaking." The nurse assesses that the client's face is puffy with edematous eyelids and the outer third of the eyebrows are thinning. What lab test will the nurse prepare the client for that is characteristic of this disorder? Troponin and myoglobin levels LDL and HDL levels BUN and creatinine T4 and TSH
T4 and TSH
An adult client has been admitted to a rehabilitation center after hospital treatment for an ischemic stroke. Which aspect of the client's history would be considered to have contributed to his stroke? The client is an Asian male. The man takes iron supplements for the treatment of chronic anemia. The client's blood pressure has historically been in the range of 150/90 to 160/100 mm Hg. The client takes corticosteroids for the treatment of rheumatoid arthritis.
The client's blood pressure has historically been in the range of 150/90 to 160/100 mm Hg.
A nurse is providing education to a client newly diagnosed with Guillain-Barré syndrome. Which statement reflects accurate information about the course of the disease? It is an acute disorder that usually resolves after treatment with antibiotics. Most clients do not sustain residual dysfunction from the disorder. The disorder may present with rapid life-threatening symptoms or may present as a slow insidious process. The client can expect prolonged isolation due to contagious viral nature of disorder.
The disorder may present with rapid life-threatening symptoms or may present as a slow insidious process.
A student is feeling inside her backpack to find her mobile phone. There are a number of other items in the backpack. Which component of somatosensory conduction is most likely to provide the detailed sensory information that will help her distinguish her phone from other items? The primary dorsal root ganglion neuron, dorsal column neuron, and the thalamic neuron A slow-conducting pathway that projects into the intralaminar nuclei of the thalamus The opposite anterolateral pathway that travels to the reticular activating system A bilateral, multisynaptic, slow-conducting tract
The primary dorsal root ganglion neuron, dorsal column neuron, and the thalamic neuron
