NSG 211 Final Practice Questions
A client with Meniere's disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo? 1. Increase fluid intake to 3000 ml a day 2. Avoid sudden head movements 3. Lie still and watch the television 4. Increase sodium in the diet
2. Avoid sudden head movements The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid sometimes are prescribed. Lying still and watching television will not control vertigo.
18. A client who is complaining of tinnitus is describing a symptom that is: 1. Objective 2. Subjective 3. Functional 4. Prodromal
2. Subjective. A subjective symptom such as ringing in the ears can be felt only by the client.
When teaching the client about Meniere's disease, which of the following instructions would a nurse give about vertigo? 1. Report dizziness at once 2. Drive in daylight hours only 3. Get up slowly, turning the entire body 4. Change your position using the logroll method
3. Get up slowly, turning the entire body Turning the entire body, not the head, will prevent vertigo. Dizziness is expected but can be prevented. The client shouldn't drive as he may reflexively turn the wheel to correct vertigo. Turning the client in bed slowly and smoothly will be helpful; logrolling isn't needed.
The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate communication? 1. Speak frequently 2. Speak loudly 3. Speak directly into the impaired ear 4. Speak in a normal tone
4. Speak in a normal tone Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.
The client with glaucoma asks the nurse is complete vision will return. The most appropriate response is: A. "Although some vision as been lost and cannot be restored. further loss may be prevented by adhering to the treatment plan." B. "Your vision will return as soon as the medications begin to work." C. "Your vision will never return to normal." D. "Your vision loss is temporary and will return in about 3-4 weeks."
A. "Although some vision as been lost and cannot be restored. further loss may be prevented by adhering to the treatment plan." Vision loss to glaucoma is irreparable. The client should be reassured that although some vision has been lost and cannot be restored. further loss may be prevented by adhering to the treatment plan. Option C does not provide reassurance to the client.
Ritalin is the drug of choice for children with ADHD. What are common side effects the RN will expect to see? A. Increased attention span and concentration B. Increase in appetite C. Sleepiness and lethargy D. Bradycardia and diarrhea
A. Increased attention span and concentration The medication has a paradoxic effect that decrease hyperactivity and impulsivity among children with ADHD. B, C, D. Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability.
When planning school interventions for a child with a attention deficit hyperactivity disorder, the RN includes? A. Provide as much structure as possible for the child B. Ignore the child's overactivity. C. Encourage the child to engage in any play activity to dissipate energy D. Remove the child from the classroom when disruptive behavior occurs
A. Provide as much structure as possible for the child Decrease stimuli for behavior control thru an environment that is free of distractions, a calm non -confrontational approach and setting limit to time allotted for activities. B. The child will not benefit from a lenient approach. C. Dissipate energy through safe activities. D. This indicates that the classroom environment lacks structure.
Mr. Lim who is diagnosed with moderate dementia has frequent catastrophic reactions during shower time. Which of the following interventions should be implemented in the plan of care? Select all that apply. A. Assign consistent staff members to assist the client. B. Accomplish the task quickly, with several staff members assisting. C. Schedule the client's shower at the same time of day. D. Sedate the client 30 minutes prior to showering. E. Tell the client to remain calm while showering. F. Use a calm, supportive, quiet manner when assisting the client.
Answer A, C, F Maintaining a consistent routine with the same staff members will help decrease the client's anxiety that occurs whenever changes are made. A calm, quiet manner will be reassuring to the client, also helping to minimize anxiety. Moving quickly with several staff will increase the client's anxiety and may precipitate a catastrophic reaction. The use of sedation is not indicated and may increase the risk of client injury from side effect of drowsiness. Telling the client to remain calm is inappropriate because a client with dementia cannot respond to such a direction.
Which of the following is not included in the care of plan of a client with a moderate cognitive impairment involving dementia of the Alzheimer's type? A. Daily structured schedule B. Positive reinforcement for performing activities of daily living C. Stimulating environment D. Use of validation techniques
Answer C A stimulating environment is a source of confusion and anxiety for a client with a moderate level of impairment and, therefore, would not be included in the plan of care. The remaining options are all appropriate interventions for this client.
The client with confusion says to the nurse, "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make? A. "I am so sorry that they didn't get you breakfast. I'll report it to the charge nurse." B. "You will have to wait a while; lunch will be here in a little while." C. "I'll get you some juice and toast. Would you like something else?" D. "You know you had breakfast 30 minutes ago."
Answer C The client who is confused might forget that he ate earlier. Don't argue with the client. Simply get him something to eat that will satisfy him until lunch.
Which of the following outcome criteria is appropriate for the client with dementia? A. The client will return to an adequate level of self-functioning. B. The client will learn new coping mechanisms to handle anxiety. C. The client will seek out resources in the community for support. D. The client will follow an established schedule for activities of daily living.
Answer D Following established activity schedules is a realistic expectation for clients with dementia. All of the remaining outcome statements require a higher level of cognitive ability that can be realistically expected of clients with this disorder.
A student nurse was asked which of the following best describes dementia. Which of the following best describes the condition? A. Memory loss occurring as part of the natural consequence of aging B. Difficulty coping with physical and psychological change C. Severe cognitive impairment that occurs rapidly D. Loss of cognitive abilities, impairing ability to perform activities of daily living
Answer D The impaired ability to perform self-care is an important measure of a client's dementia progression and loss of cognitive abilities. Difficulty or impaired ability to perform normal activities of daily living, such as maintaining hygiene and grooming, toileting, making meals, and maintaining a household, are significant indications of dementia. Slowing of processes necessary for information retrieval is a normal consequence of aging. However, the global statement that memory loss occurs as part of natural aging is not true. Dementia is not normal; it is a disease. Difficulty coping with changes can be experienced by any client, not just one with dementia. The rapid occurrence of cognitive impairment refers to delirium.
During the home visit of a client with dementia, the nurse notes that an adult daughter persistently corrects her father's misperceptions of reality, even when the father becomes upset and anxious. Which intervention should the nurse teach the caregiver? A. Anxiety-reducing measures B. Positive reinforcement C. Reality orientation techniques D. Validation techniques
Answer D Validation techniques are useful measures for making emotional connections with a client who can no longer maintain reality orientation. These measures are also helpful in decreasing anxiety. Anxiety-reducing measures and positive reinforcements will also be appropriate, but validation techniques will provide both anxiety reduction and positive reinforcement for the client. Reality orientation techniques are not useful when the client can no longer maintain reality contact and becomes upset when misperceptions are corrected.
On a 24-hour assessment, the nurse documents that a client diagnosed with Alzheimer's disease presents with aphasia. Which client behavior supports this finding? 1. The client is sad and has no ability to experience pleasure. 2. The client is extremely emaciated and appears to be wasting away. 3. The client is having difficulty in forming words. 4. The client is no longer able to speak.
Answer is 3! 1.Anhedonia, not aphasia, is the term used when an individual is sad and has no ability to experience or even imagine any pleasant emotion. 2. Cachexia, not aphasia, is the term used when an individual is in ill health and experiencing malnutrition and wasting. This may occur in many chronic diseases, certain malignancies, and advanced pulmonary tuberculosis. 3. Aphasia is the term used when an individual is having difficulty communicating through speech, writing, or signs. This is often caused by dysfunction of brain centers. Aphasia is a cardinal symptom observed in Alzheimer's disease. 4. Aphonia, not aphasia, is the term used when an individual is no longer able to speak. This may result from chronic laryngitis, laryngeal nerve damage, brain lesions, or psychiatric causes, such as hysteria.
Which comment about a 3-year-old child if made by the parent may indicate child abuse? A. "Once my child is toilet trained, I can still expect her to have some." B. "When I tell my child to do something once, I don't expect to have to tell them again." C. "My child is expected to try to do things such as dress and feed." D. "My three (3)-year-old loves to say NO."
B. "When I tell my child to do something once, I don't expect to have to tell them again." Abusive parents tend to have unrealistic expectations on the child. A,B and C are realistic expectations on a 3 year old.
Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client's chart and understands that normal intraocular pressure is: A. 2-7 mmHg B. 10-21 mmHg C. 22-30 mmHg D. 31-35 mmHg
B. 10-21 mmHg
A 5-year-old boy is diagnosed to have autistic disorder. Which of the following manifestations may be noted in a client with autistic disorder? A. Argumentativeness, disobedience, angry outburst B. limited social skills, labile mood, Intolerance to change C. Distractibility, impulsiveness, and overactivity D. Aggression, truancy, stealing, lying
B. limited social skills, labile mood, Intolerance to change These are manifestations of autistic disorder. A. These manifestations are noted in Oppositional Defiant Disorder, a disruptive disorder among children. C. These are manifestations of Attention Deficit Disorder D. These are the manifestations of Conduct Disorder
While assessing an older pt, the daughter states that the pt used her toothbrush to comb her hair. She is manifesting: A. Apraxia B. Aphasia C. Agnosia D. Amnesia
C. Agnosia This is the inability to recognize familiar objects. A. Apraxia is the inability to execute motor activities and repeated instructions are needed to perform the simplest task B. Aphasia is the loss of ability to use or understand words. D. Amnesia is loss of memory.
The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following. if stated by the client. indicates an understanding of the instructions? A. "I will take Aspirin if I have any discomfort." B. "I will sleep on the side that I was operated on" C. "I will wear my eye shield at night and my glasses during the day." D. "I will not lift anything if it weighs more that 10 pounds."
C. "I will wear my eye shield at night and my glasses during the day. The client is instructed to wear a metal or plastic shield to protect the eye from accidental pressure and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the side of the body on which the operation occurred. The client is not to lift more than 5 pounds.
During the early postoperative period. the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: A. Elevate the head of the bed 30 degrees B. Assess the color of drainage C. Notify the Physician D. Administer Analgesics
C. Notify the Physician Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the physician immediately. The other options are inappropriate.
The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client: A. Receives adequate nutrition and hydration B. Will reminisce to decrease isolation C. Remains in a safe and secure environment D. Independently performs self-care
C. Remains in a safe and secure environment Safety is a priority consideration as the client's cognitive ability deteriorates.. A is appropriate interventions because the client's cognitive impairment can affect the client's ability to attend to his nutritional needs, but it is not the priority B. Patient is allowed to reminisce but it is not the priority. D. The client in the moderate stage of Alzheimer's disease will have difficulty in performing activities independently
The therapeutic approach in the care of an autistic child includes the following EXCEPT: A. Engage in diversionary activities when acting out B. Provide an atmosphere of acceptance C. Provide safety measures D. Rearrange the environment to activate the child
D. Rearrange the environment to activate the child The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. A. Angry outburst can be rechannelled through safe activities. B. Acceptance enhances a trusting relationship. C. Ensure safety from self-destructive behaviors like head banging and hair pulling.
The client diagnosed with Alzheimer's disease is prescribed galantamine (Reminyl), a cholinesterase inhibitor. Which interventions should the nurse implement? Select all that apply. 1. Inform the client to take the medication with food. 2. Check the client's BUN and creatinine levels. 3. Teach the client to wear a MedicAlert bracelet with information about the medication. 4. Assess the client's other routine medications. 5. Discuss not abruptly discontinuing the medication.
The answer 1, 2, 4 Reminyl's most common side effect is gastrointestinal disturbance. This can be minimized if the medication is taken with food. 2. Reminyl is excreted by the kidneys. The dose is limited for clients with renal or liver impairment and used with caution in clients with severe impairment. 3. There is no reason to require the client to wear a MedicAlert bracelet. All clients should keep a list of current medications with them in case of an emergency. 4. The effects of cholinesterase inhibitors may be reduced by first-generation antihistamine medications, tricyclic antidepressants, and antipsychotics, and the client should not take these medications simultaneously. The nurse should ask the client about other medications taken. 5. The medication does not have to be tapered off to avoid adverse effects. MEDICATION MEMORY JOGGER: Because the hepatic and renal systems are responsible for metabolizing and excreting all medications, monitoring the liver and kidney laboratory values is a pertinent nursing action.
Which statement is the advantage of prescribing donepezil (Aricept) over the other cholinesterase inhibitors? 1. The dosing schedule for Aricept is only once a day. 2. Aricept is the only one that can be given with an NSAID. 3. Aricept enhances the cognitive protective effects of vitamin E. 4. There are no side effects of Aricept.
The answer is 1! 1. An advantage of Aricept is once-a-day dosing. Research has proved that the more doses required to be taken each day, the less the actual compliance with the medication regimen. Additionally, Aricept is not hepatotoxic and is better tolerated than some of the cholinesterase inhibitors. 2. There is no contraindication to administering NSAIDs and cholinesterase inhibitors simultaneously. 3. Aricept does not enhance vitamin E. 4. There are side effects with any medications. The common side effects of Aricept are nausea, diarrhea, and bradycardia.
The client diagnosed with Alzheimer's disease (AD) is prescribed rivastigmine (Exelon), a cholinesterase inhibitor. Which medication should the nurse question administering to the client? 1. Amitriptyline (Elavil), a tricyclic antidepressant. 2. Warfarin (Coumadin), an anticoagulant. 3. Phenytoin (Dilantin), an anticonvulsant. 4. Prochlorperazine (Compazine), an antiemetic.
The answer is 1! 1.Tricyclic antidepressants, first-generation antihistamines, and antipsychotics can reduce the client's response to cholinesterase inhibitors. Antipsychotics are useful for clients whose behavior is erratic and uncontrollable in the end stage of the disease. The cholinesterase inhibitor Exelon would not be useful in end-stage disease. 2. Coumadin interacts with several medications but not with cholinesterase inhibitors. 3. Cholinesterase inhibitors do not interact with Dilantin. 4. Compazine may be used to control the nausea produced by Exelon; there is no reason to question administering this medication.
Which statement is the scientific rationale for prescribing and administering donepezil (Aricept), a cholinesterase inhibitor? 1. Aricept works to bind the dopamine at neuron receptor sites to increase ability. 2. Aricept increases the availability of acetylcholine at cholinergic synapses. 3. Aricept decreases acetylcholine in the periphery to increase movement. 4. Aricept delays transmission of acetylcholine at the neuronal junction.
The answer is 2! 1. Aricept does not bind dopamine. 2. Cholinesterase inhibitors increase the availability of acetylcholine at cholinergic synapses, resulting in increased transmission of acetylcholine by cholinergic neurons that have not been destroyed by the Alzheimer's disease. 3. Aricept does not decrease acetylcholine in the periphery. 4. Aricept enhances the availability of acetyl- choline at the receptor sites.
A client newly diagnosed with Alzheimer's disease was admitted 72 hours ago. The client states, "Last night I went on a wonderful dinner cruise." Which type of communication is this client expressing, and what is the underlying reason for its use? 1. The client is using confabulation to achieve secondary gains. 2. The client is using confabulation to protect the ego. 3. The client is using perseveration to divert attention. 4. The client is using perseveration to maintain self-esteem.
The answer is 2! The client in the question is using confabulation. Confabulation is the creation of imaginary events to fill in memory gaps. 1. Although the client is using confabulation, the underlying reason is to protect the ego by maintaining self-esteem, not to achieve secondary gains. 2. Clients diagnosed with Alzheimer's disease use confabulation to create imaginary events to fill in memory gaps. This "hid- ing" is actually a form of denial, which is a protective ego defense mechanism used to maintain self-esteem and avoid losing one's place in the world. 3. The client in the question is using confabulation, not perseveration. A client who exhibits perseveration persistently repeats the same word or idea in response to different questions. 4. Although maintaining self-esteem is important for individuals diagnosed with Alzheimer's disease, the use of perseveration does not increase self-esteem. The client in the question is using confabulation, not perseveration. A client who exhibits perseveration persistently repeats the same word or idea in response to different questions.
A client diagnosed with dementia states, "I can't believe it's the 4th of July and it's snowing outside." Which is the nurse's most appropriate response? 1. "What makes you think it's the 4th of July?" 2. "How can it be July in winter?" 3. "Today is March 12, 2007. Look, your lunch is ready." 4. "I'll check to see if it's time for your PRN haloperidol (Haldol)."
The answer is 3! 1. Questioning the client's perception shows contempt for the client's ideas or behaviors. Asking a client to provide reasons for thoughts can be intimidating and implies that the client must defend his or her behavior or feelings. 2. Challenging the client belittles the client and discourages further interactions. 3. Orienting the client to person, place, and time, as necessary, refocuses the client to the here and now. Casually reminding the client of a noon meal redirects the client in a manner that is considerate and respectful. It is imperative to preserve the client's self-esteem. 4. PRN medication at this time would do noth- ing to reorient the client to the here and now. PRN haloperidol (Haldol) would be appro- priate if the client were exhibiting agitation or uncontrolled behavior, not confusion and disorientation. TEST-TAKING HINT: When clients are diagnosed with dementia, it is important to preserve self- esteem. These clients do not have the capacity to correct impaired orientation. When the nurse challenges the client's thought processes, as in "1" and "2," the client's self-esteem is decreased. Medicating a client, as in "4," without pursuing other avenues of problem solving is inappropriate.
A client who is delirious yells out to the nurse, "You are an idiot, get me your supervisor." Which is the best nursing response in this situation? 1. "You need to calm down and listen to what I'm saying." 2. "You're very upset, I'll call my supervisor." 3. "You're going through a difficult time. I'll stay with you." 4. "Why do you feel that my calling the supervisor will solve anything?"
The answer is 3! 1. Telling a client who is experiencing delirium to calm down and listen is unrealistic. The client's reasoning ability and goal-directed behavior are impaired, and the client is unable to calm down or listen. 2. Acknowledging that the client is upset promotes understanding and trust, but the nurse in this situation can address the client's symptoms appropriately by frequent orientation to reality without calling the supervisor. 3. Empathetically expressing understanding of the client's situation promotes trust and may have a calming effect on the client. Delirious or confused clients may be at high risk for injury and should be monitored closely. 4. Requesting an explanation from a client regarding reasons for feelings, thoughts, or behaviors in any situation, especially a situation in which a client is experiencing delirium, is nontherapeutic.
The family member of a client diagnosed with early-stage Alzheimer's disease (AD) who was prescribed the cholinesterase inhibitor donepezil (Aricept) without improvement asks the nurse, "Can anything be done to slow the disease since this medication does not work?" Which statement is the nurse's best response? 1. "I am sorry that the medication did not help. Would you like to talk about it?" 2. "You need to prepare for long-term care because confusion is inevitable now." 3. "Your loved one may respond to a different medication of the same type." 4. "No, nothing is going to slow the disease now. Have the client make a will."
The answer is 3! 1. There are three other medications in the classification of cholinesterase inhibitors that may be tried because the medications are not identical. Additionally, vitamin E in large doses, selegiline, and Gingko biloba have been shown to slow progression of AD. This answer on the part of the nurse is not providing information and is not directly answering the family member's question. 2. The progression of AD is inevitable at some point. Cholinesterase inhibitors are prescribed for clients with mild to moderate symptoms of AD, and they can delay the progression of AD. This is not the time to discuss long-term care. 3. If the client does not respond to one of the cholinesterase inhibitors, then another may be tried because the drugs are not identical. The client may be responsive to a different medication in the same classification. 4. There are more options to discuss regard- ing treatment of AD at this time.
