PrepU exam 4 med surg
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? Therapy is not necessary prophylactically and should only be used if the person develops symptoms. Within 48 hours after exposure Within 24 hours after exposure Within 72 hours after exposure
Within 24 hours after exposure
The community health nurse is conducting a home visit with a client who was discharged from hospital 3 days ago after surgical resection of a brain tumor and radiation therapy. The client is accompanied by his partner during the nurse's visit. During the visit, the client's partner becomes tearful. How should the nurse respond?
"Going through this experience with your partner has been very difficult for you, I'm sure. Can you tell me about your experience so far?"
The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain? "I was putting my shoes on." "I was sitting at home watching television." "I was taking a bath." "I was brushing my teeth."
"I was brushing my teeth."
A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction? "Take your temperature every 4 hours." "Apply an antibacterial dressing to the incision daily." "Be aware that your urine will be cherry-red for 5 to 7 days." "Increase your fluid intake to 2 to 3 L per day."
"Increase your fluid intake to 2 to 3 L per day."
A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process? "When it clears up, it will never come back." "It will never get any better than it is right now." "I'll definitely need surgery for this." "It will get better and worse again."
"It will get better and worse again."
A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." "OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints." "OA is more common in women. RA is more common in men." "OA affects joints on both sides of the body. RA is usually unilateral."
"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
A client with osteoarthritis expresses concerns that the disease will prevent the ability to complete daily chores. Which suggestion should the nurse offer? "Do all your chores in the morning, when pain and stiffness are least pronounced." "Do all your chores after performing morning exercises to loosen up." "Do all your chores in the evening, when pain and stiffness are least pronounced." "Pace yourself and rest frequently, especially after activities."
"Pace yourself and rest frequently, especially after activities."
A client with gout has been advised to lose weight. The client informs the nurse of plans to go on a "guaranteed rapid weight loss" plan that involves fasting and heavy exercise. Which response would be most appropriate? "The fasting is okay, but make sure you drink fluids when exercising." "Try combining the fasting with moderate exercise." "There might be some difficulties with your plan and fasting." "Make sure to eat some fat occasionally with all that exercise."
"There might be some difficulties with your plan and fasting."
A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide? "Your type of MS is the least common, making it difficult to manage." "You must avoid stress and extreme fatigue, because these can trigger a relapse." "You should take your medications only during times of relapse." "You will have a steady and gradual decline in function."
"You must avoid stress and extreme fatigue, because these can trigger a relapse."
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? Trendelenburg's 30-degree head elevation Flat Side-lying
30-degree head elevation
As part of the assessment process for a client suspected of having gout, the nurse evaluated the client's serum uric acid levels. Select the value that is considered above the saturation point for crystal formation. 5.4 mg/dL (0.32 mmol/L) 4.0 mg/dL (0.24 mmol/L) 6.8 mg/dL (0.40 mmol/L) 3.2 mg/dL (0.19mmol/L)
6.8 mg/dL (0.40 mmol/L)
The earliest sign of serious impairment of brain circulation related to increased ICP is: A change in consciousness. Hypertension. A bounding pulse. Bradycardia.
A change in consciousness.
The nurse is employed in a urologist's office. Which classification of medication is anticipated for clients having difficulty with urinary incontinence? Diuretics Anticonvulsant Cholinergic Anticholinergic
Anticholinergic
Which nursing intervention is the priority for a client in myasthenic crisis? Assessing respiratory effort Ensuring adequate nutritional support Preparing for plasmapheresis Administering intravenous immunoglobin (IVIG) per orders
Assessing respiratory effort
The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following? Lymphoma Leukemia Virus Bacteria
Bacteria
A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture? Simple Basilar Comminuted Linear
Basilar
A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture? Simple Comminuted Depressed Basilar
Basilar
A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern? Bull's eye rash Butterfly rash Pustular rash Papular rash
Butterfly rash
The nurse is educating a client about the risks of stroke related to the new prescription for a COX-2 inhibitor and what symptoms to report. Which COX-2 inhibitor is the nurse educating the client about? Celecoxib Tolmetin sodium Piroxicam Ibuprofen
Celecoxib
What is the most common presenting objective symptom of a urinary tract infection in older adults, especially in those with dementia? Back pain Incontinence Hematuria Change in cognitive functioning
Change in cognitive functioning
Which of the following is the earliest sign of increasing intracranial pressure (ICP)? Seizures Pupil changes Change in level of consciousness (LOC) Restlessness
Change in level of consciousness (LOC)
The nurse is teaching a client about the characteristics of osteoarthritis. How will the nurse determine the client teaching was successful? Clients will develop boutonniere deformity. Clients may develop Heberden nodes. Clients may have swan neck deformity. Clients will have an ulnar deviation.
Clients may develop Heberden nodes.
After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the students have understood the material when they identify which of the following as a cause of stress incontinence? Decreased pelvic muscle tone due to multiple pregnancies Bladder irritation related to urinary tract infections Increased urine production due to metabolic conditions Obstruction due to fecal impaction or enlarged prostate
Decreased pelvic muscle tone due to multiple pregnancies
An older adult client is being evaluated for suspected pyelonephritis and is ordered kidney, ureter, and bladder (KUB) x-ray. The nurse understands the significance of this order is related to which rationale? Shows damage to the kidneys Reveals causative microorganisms Detects calculi, cysts, or tumors If risk for chronic pyelonephritis is likely
Detects calculi, cysts, or tumors
A client is receiving treatment for an acute episode of gout with colchicine. The nurse is administering the medication every 2 hours. What should the nurse be sure the client communicates so that the drug can be temporarily stopped? Select all that apply. Increase in pain in the affected extremity Nausea and vomiting Intestinal cramping Diarrhea Tingling in the arms
Diarrhea Intestinal cramping Nausea and vomiting
Which instruction would be included in a teaching plan for a client diagnosed with a urinary tract infection? Void every 4 to 6 hours. Drink liberal amount of fluids. Drink coffee or tea to increase diuresis. Use tub baths as opposed to showers.
Drink liberal amount of fluids.
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly decribes Battle's sign? Drainage of cerebrospinal fluid from the nose Ecchymosis over the mastoid Drainage of cerebrospinal fluid from the ears Bruising under the eyes
Ecchymosis over the mastoid
The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate? Edema to the head and a blackened eye Edema to the head with bruising of the mastoid process Edema to the head with a large scalp laceration Edema to the head with fixed pupils
Edema to the head with bruising of the mastoid process
Which of the following topics would be most important to include when teaching a patient with Multiple Sclerosis?
Effect of stress and fatigue on symptoms
The nurse is reviewing the diagnostic test findings of a client with rheumatoid arthritis. What would the nurse expect to find? Elevated erythrocyte sedimentation rate Increased red blood cell count Increased albumin levels Increased C4 complement
Elevated erythrocyte sedimentation rate
Which is an appropriate nursing intervention in the care of the client with osteoarthritis? Avoid the use of topical analgesics Provide an analgesic after exercise Assess for gastrointestinal complications associated with COX-2 inhibitors Encourage weight loss and an increase in aerobic activity
Encourage weight loss and an increase in aerobic activity
A client is scheduled for an MRI. What is the priority safety action prior to this diagnostic procedure?
Ensuring that there are no metal objects on or in the client
The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available? Equipment to maintain infection control precautions Extra lighting IV tensilon Nasogastric tubing
Equipment to maintain infection control precautions
The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis? Fatigue and depression Facial distortion and pain Hyporeflexia and weakness of the lower extremities Ptosis and diplopia SUBMIT ANSWER
Facial distortion and pain
The nurse teaches the client that the presence of crystals in the synovial fluid obtained from arthrocentesis confirms which disease process? Gout Infection Degeneration Inflammation
Gout
While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have? Grade 4 concussion Grade 3 concussion Grade 2 concussion Grade 1 concussion
Grade 3 concussion
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe? Ptosis and diplopia Hyporeflexia in the lower extremities Numbness and vomiting Headache and nuchal rigidity
Headache and nuchal rigidity
The nurse is obtaining a health history from a client describing urinary complications. Which assessment finding is most suggestive of a malignant tumor of the bladder? Incontinence Hematuria Dysuria Frequency
Hematuria
A nurse is assisting with the assessment of a client with suspected brain abscess. Which of the following findings would be consistent with such an abscess in the frontal lobe of the brain? Select all that apply. Expressive aphasia Seizures Changes in vision Nystagmus Hemiparesis
Hemiparesis Seizures Expressive aphasia
A patient is hospitalized with a severe case of gout. The patient has gross swelling of the large toe and rates pain a 10 out of 10. With a diagnosis of gout, what should the laboratory results reveal? Hyperuricemia Ketonuria Hyperproteinuria Glucosuria
Hyperuricemia
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? Increased pulse rate, adventitious breath sounds Increased pulse rate, respirations of 16 breaths/minute Decreased pulse rate, respirations of 20 breaths/minute Decreased pulse rate, abdominal breathing
Increased pulse rate, adventitious breath sounds
The nurse is caring for a client with increased intracranial pressure (ICP) after surgical resection of a brain tumor. The nurse recognizes the client is demonstrating late signs of ICP when which sign is observed? Irregular respirations Tachycardia Hypotension Low pulse pressure
Irregular respirations
A patient with a brain injury has a MAP of 50 mm Hg and an ICP of 5 mm Hg. The nurse knows the CPP is:
Low
A patient who has been treated for uric acid stones is being discharged from the hospital. What type of diet does the nurse discuss with the patient? Low-calcium diet Low-phosphorus diet Low-purine diet High-protein diet
Low-purine diet
Which is the most common cause of spinal cord injury (SCI)? Sports-related injuries Acts of violence Motor vehicle crashes Falls
Motor vehicle crashes
The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? Tylenol may be administered for aches. Observe for any signs of behavioral changes. A light meal may be eaten if desired. Follow up with regular physician is encouraged.
Observe for any signs of behavioral changes.
If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection? Perform meticulous perineal care daily with soap and water Place the catheter bag on the client's abdomen when moving the client Use a sterile technique to disconnect the catheter from the tubing to obtain urine specimens Use a clean technique during insertion
Perform meticulous perineal care daily with soap and water
Which of the following interventions is most appropriate for the client experiencing a tonic-clonic seizure?
Protect the extremities from contact with other objects
Which term refers to inflammation of the renal pelvis? Interstitial nephritis Cystitis Pyelonephritis Urethritis
Pyelonephritis
A patient with a UTI is having burning and pain when urinating. What urinary analgesic is prescribed for relief of these symptoms? Bactrim Pyridium Septra Levaquin
Pyridium
The nurse knows that a patient who presents with the symptom of "blanching of fingers on exposure to cold" would be assessed for what rheumatic disease? Reiter's syndrome Raynaud's phenomenon Sjögren's syndrome Ankylosing spondylitis
Raynaud's phenomenon
A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective? Reduced muscle spasticity Increased ability to sleep Relief from constipation Relief from pain
Reduced muscle spasticity
The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily? Skin Respiratory Gastrointestinal Urinary SUBMIT ANSWER
Respiratory
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? Dressing or grooming self-care deficit Risk for injury Disturbed sensory perception (visual) Impaired verbal communication
Risk for injury
A patient with a T4 spinal cord injury complains of a pounding headache, HR 54, and BP 190/100. What should you do?
Sit the patient up and correct underlying cause
Which condition occurs when blood collects between the dura mater and arachnoid membrane? Epidural hematoma Extradural hematoma Subdural hematoma Intracerebral hemorrhage
Subdural hematoma
Which condition occurs when blood collects between the dura mater and arachnoid membrane? Epidural hematoma Intracerebral hemorrhage Subdural hematoma Extradural hematoma
Subdural hematoma
Which of the following disorders is characterized by an increased autoantibody production? Systemic lupus erythematosus (SLE) Scleroderma Rheumatoid arthritis (RA) Polymyalgia rheumatic
Systemic lupus erythematosus (SLE)
Which of the following is not a manifestation of Cushing's Triad? Bradypnea Tachycardia Bradycardia Hypertension
Tachycardia
When teaching about anticholinesterase medications, which intervention is most useful to a patient with myasthenia?
Take medication 30 minutes prior to eating or activity
The nurse is educating a female patient with a UTI on the pharmacologic regimen for treatment. What is important for the nurse to instruct the patient to do? Take the antibiotic as well as an antifungal for the yeast infection she will probably have. Understand that if the infection reoccurs, the dose will be higher next time. Be sure to take the medication with grapefruit juice. Take the antibiotic for 3 days as prescribed.
Take the antibiotic for 3 days as prescribed.
A client is taking ibuprofen for the treatment of osteoarthritis. What education will the nurse give the client about the medication? Inform the health care provider if there is ringing in the ears. Since the medication is able to be obtained over the counter, it has few side effects. Take the medication on an empty stomach in order to increase effectiveness. Take the medication with food to avoid stomach upset.
Take the medication with food to avoid stomach upset.
A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine positivity for the disorder. Which statement by the nurse is most accurate? "The diagnosis won't be based on the findings of a single test but by combining all data found." "SLE is a very serious systemic disorder." "Tell me more about your concerns about this potential diagnosis." "You should discuss that matter with your health care provider."
The diagnosis won't be based on the findings of a single test but by combining all data found."
Which of the following is the procedure of choice for men with recurrent or complicated urinary tract infections (UTIs)? Computed tomography (CT) scan Magnetic resonance imaging (MRI) IV urogram Transrectal ultrasonography
Transrectal ultrasonography
A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? Bedrest at home for 72 hours Admission to the nearest hospital for observation Treatment with antimicrobial prophylaxis as soon as possible No treatment unless the roommate begins to show symptoms SUBMIT ANSWER
Treatment with antimicrobial prophylaxis as soon as possible
A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence? Functional Overflow Urge Stress
Urge
A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect? Acute glomerulonephritis Ureteral stricture Urinary calculi Renal cell carcinoma
Urinary calculi
A client with aphasia says, "I want a...." and then stops speaking. Which response by the nurse is best?
Wait for the client to complete the sentence
A client is recovering from an attack of gout. What will the nurse include in the client teaching? Weight loss will reduce purine levels. Weight loss will reduce uric acid levels and reduce stress on joints. Weight loss will increase uric acid levels and reduce stress on joints. Weight loss will reduce inflammation.
Weight loss will reduce uric acid levels and reduce stress on joints.
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a positive sweat chloride test. a positive edrophonium (Tensilon) test. Brudzinski's sign. Kernig's sign. SUBMIT ANSWER
a positive edrophonium (Tensilon) test.
Fibromyalgia is a common condition that involves chronic fatigue, generalized muscle aching, and stiffness. generalized muscle aching, mood swings, and loss of balance. pain, viral infection, and tremors. diminished vision, chronic fatigue, and reduced appetite.
chronic fatigue, generalized muscle aching, and stiffness.
The presence of crystals in synovial fluid obtained from arthrocentesis is indicative of infection. degeneration. gout. inflammation.
gout.
The nurse is discussing life management with the client with rheumatoid arthritis in a health clinic. What assessment finding indicates the client is having difficulty implementing self-care? ability to perform activities of daily living (ADL) increased fatigue a weight gain of 2 pounds decreased joint pain
increased fatigue
The nurse is discussing life management with the client with rheumatoid arthritis in a health clinic. What assessment finding indicates the client is having difficulty implementing self-care? decreased joint pain increased fatigue a weight gain of 2 pounds ability to perform activities of daily living (ADL)
increased fatigue
Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia all have the same type of symptoms. rarely respond to treatment. will eventually lose their ability to walk. may feel as if their symptoms are not taken seriously.
may feel as if their symptoms are not taken seriously.
A diet plan is developed for a client with gouty arthritis. What should the nurse advise the client to limit the intake of? citrus fruits fresh fish organ meats green vegetables
organ meats
A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase? assessing vital signs frequently destabilizing client's condition reporting changes to the physician preventing further neurologic damage
preventing further neurologic damage
Which of the following would a nurse encourage a client with gout to limit? protein-rich foods carbohydrates fluid intake purine-rich foods
purine-rich foods
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? Take daily weights. Assess for pupillary response frequently. Assess vital signs frequently. Reposition the client frequently.
take daily weights.
A client who has a history of neurogenic bladder presents with fever, burning, and suprapubic pain. What would the nurse suspect is the problem? urinary retention urinary tract infection urinary incontinence urethral strictures
urinary tract infection
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client vomits. reports a headache. sleeps for short periods of time. reports generalized weakness.
vomits.
The nurse is performing a health history with a new client with fibromyalgia. What will the nurse expect to assess as the most common finding associated with fibromyalgia? Heberden nodes widespread chronic pain butterfly facial rash jaw locking
widespread chronic pain
A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP? Cluster all procedures together. Keep the head of the client's bed flat. Keep the client's neck in a neutral position (no flexing). Avoid sedation.
Keep the client's neck in a neutral position (no flexing).
Which medication is the most effective agent in the treatment of Parkinson disease? Levodopa Bromocriptine mesylate Benztropine Amantadine
Levodopa
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? Look for a halo sign Have the client avoid physical exertion Emphasize complete bed rest Look for signs of increased intracranial pressure
Look for signs of increased intracranial pressure
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? Sciatic nerve pain Paralysis Paresthesia Herniation
Paresthesia
Scleroderma typically starts with which type of organ involvement? Skin Lung Kidney Brain
Skin
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)? Computed tomography (CT) scan Electromyogram (EMG) Serum studies Tensilon test
Tensilon test
A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? Administering ordered analgesics and monitoring their effects Performing meticulous skin care Supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware Providing comprehensive client teaching; including symptoms of the disorder, treatment options, and expected outcomes
Administering ordered analgesics and monitoring their effects
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? A subdural hematoma An extradural hematoma An epidural hematoma An intracerebral hematoma
An intracerebral hematoma
The nurse working with a client after an ileal conduit notices that the pouching system is leaking small amounts of urine. What is the appropriate nursing intervention? Secure or patch it with barrier paste. Change the wafer and pouch. Secure or patch it with tape. Empty the pouch.
Change the wafer and pouch
The nurse has been asked to provide health information to a female patient diagnosed with a urinary tract infection. What appropriate instructions will the nurse provide? Select all that apply. Cleanse around the perineum and urethral meatus after each bowel movement to reduce pathogens. Drink caffeinated beverages twice a day to increase urination. Drink liberal amounts of fluid to flush out bacteria. Void every 2-3 hours to prevent overdistention of the bladder Bathe in warm water to soak the affected area.
Cleanse around the perineum and urethral meatus after each bowel movement to reduce pathogens. Drink liberal amounts of fluid to flush out bacteria. Void every 2-3 hours to prevent overdistention of the bladder
A client is being admitted to a rehabilitation hospital as a result of the tetraplegia caused a stroke. The client's condition is stable, and after admission the client will begin physical and psychological therapy. An important part of nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention? passive exercise maintain sufficient integument capillary pressure provide a change of scenery maintain psychological well-being
maintain sufficient integument capillary pressure
A 64-year-old man is seeing his urologist for an annual check-up, post prostatectomy. The health care provider is concerned with the symptom he finds because it is considered diagnostic for bladder cancer. Which of the following signs/symptoms is diagnostic for bladder cancer? Painless, gross hematuria Decreasing kidney function associated with fever and hematuria Muscle spasm and abdominal rigidity over the flank Deep flank and abdominal pain
Painless, gross hematuria
Which assessment suggests to the nurse that a client with systemic lupus erythematous is having renal involvement? Behavioral changes Chest pain Decreased cognitive ability Hypertension
Hypertension
The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is Sports-related injuries Falls Acts of violence Motor vehicle crashes
Motor vehicle crashes
The nurse is assessing a client with a history of ankylosing spondylitis. What will the nurse most commonly assess? low back pain increased urine output patchy hair loss on the scalp red, butterfly-shaped facial rash
low back pain
Corticosteroids are used in the management of brain tumors to facilitate regeneration of neurons. reduce cerebral edema. identify precise location of the tumor. prevent extension of the tumor.
reduce cerebral edema.
Which Glasgow Coma Scale score is indicative of a severe head injury? 7 9 11 13
7
A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include? Take moderate amounts of alcohol. Avoid hot temperatures. Avoid analgesic medication. Avoid physical activity.
Avoid hot temperatures
A pt admitted to the ER after an auto crash is found to have BAC of 0.21%. The pt is alert, can relate info related to the crash, and does not appear intoxicated. Which action should the nurse take?
obtain a accurate history of alcohol intake
The nurse teach the client that osteoarthritis is affects young males. the most common and frequently disabling of joint disorders. requires early treatment because most of the damage appears to occur early in the course of the disease. affects the cartilaginous joints of the spine and surrounding tissues.
the most common and frequently disabling of joint disorders.
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? "The paralysis caused by this disease is temporary." "It must be hard to accept the permanency of your paralysis." "You'll be permanently paralyzed; however, you won't have any sensory loss." "You'll first regain use of your legs and then your arms."
"The paralysis caused by this disease is temporary."
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse? "Don't worry; your child will be fine." "It's too early to give a prognosis." "Once Guillain-Barré syndrome progresses to the diaphragm, survival decreases significantly." "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."
"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."
The nurse is teaching a client with osteoarthritis about the disease. What is the mostimportant client focus for disease management? strategies for remaining active disease-modifying antirheumatic drug therapy detection of systemic complications prevention of joint deformity
strategies for remaining active
The nurse is assessing a patient with a diagnosis of scleroderma. What clinical manifestations of scleroderma does the nurse assess? (Select all that apply.) Productive cough Decreased ventilation owing to lung scarring Dyspnea owing to fibrotic cardiac tissue Dysphagia owing to hardening of the esophagus Butterfly-shaped rash on the face
Decreased ventilation owing to lung scarring Dysphagia owing to hardening of the esophagus Dyspnea owing to fibrotic cardiac tissue
A pt tells the nurse that is worried about her 12 yr old son who has been socializing with some friends she thinks that are using drugs: the best response by the nurse to a patient's concern is
"you should learn about the early signs and symptoms of drug abuse and share your concerns with your son"
The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication? 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days 1 hour after the antibiotic has infused and daily for 7 days It can be administered every 6 hours for 10 days. 2 hours prior to the administration of antibiotics for 7 days
15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client? A disorder in which the body has too many immunoglobulins A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" A disorder in which the body does not have enough immunoglobulins A disorder in which histocompatible cells attack the immunoglobulins
A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"
Which nursing diagnosis is appropriate for the client with a new ileal conduit? Select all that apply. Chronic pain Urinary retention Disturbed body image Risk for impaired skin integrity Deficient knowledge: management of urinary diversion
Deficient knowledge: management of urinary diversion Disturbed body image Risk for impaired skin integrity
The nurse is conducting a community education program on UTIs. The nurse determines that the participants understand the teaching when they identify which factor as contributing to UTIs in older adults? Immunocompromise Active lifestyle Sporadic use of antimicrobial agents Low incidence of chronic illness
Immunocompromise
Which points should be included in the medication teaching plan for a client taking adalimumab? The medication is given at room temperature. It is important to monitor for injection site reactions. The client should continue taking the medication if fever occurs. The medication is administered intramuscularly.
It is important to monitor for injection site reactions.
The most important nursing priority of treatment for a patient with an altered LOC is to: Prevent dehydration and renal failure by inserting an IV line for fluids and medications. Maintain a clear airway to ensure adequate ventilation. Position the patient to prevent injury and ensure dignity. Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain.
Maintain a clear airway to ensure adequate ventilation.
A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse? Call the physician. Assess the patient for a fecal impaction. Place the patient in a sitting position. Assess the patient for a full bladder.
Place the patient in a sitting position.
A client has had several diagnostic tests to determine if he has systemic lupus erythematosus (SLE). What result is very specific indicator of this diagnosis? Positive Anti-dsDNA antibody test Elevated ESR Positive ANA titre Positive Anti-Sm antibodies
Positive Anti-dsDNA antibody test
A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to: assess for infection. prevent embolism. follow hospital protocol. decrease the potential for brain damage.
decrease the potential for brain damage.
Sympathomimetics have which of the following effects on the body? Constriction of pupils Decrease of heart rate Relaxation of bladder wall Constriction of bronchioles
Relaxation of bladder wall
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Hepatic Musculoskeletal Renal Integumentary
Renal
A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose? The muscles will become fatigued and the patient will not be able to chew food or swallow pills. The patient will require a double dose prior to lunch. There should not be a problem, since the medication was only delayed by about 2 hours. The patient will go into cardiac arrest.
The muscles will become fatigued and the patient will not be able to chew food or swallow pills.
Which of the following nutritional considerations are important for the patient with Parkinson's Disease?
The patient should be upright (seated) during meals
The nurse is caring for a client with recurrent urinary tract infections. Which of the following body structures would the nurse instruct as the most frequent cause of women's urinary tract infections? The urethra The bladder The ureters The rectum
The urethra
Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage? Pannus Tophi Joint effusion Subchondral bone
Tophi
The nurse is performing a health history with a new client in the clinic. What is the mostcommon reason for a client to seek medical attention for arthritis? weakness stiffness joint swelling pain
pain
The nurse is assisting in the development of a protocol for bladder retraining following removal of an indwelling catheter. Which item should the nurse include? Encourage voiding immediately after catheter removal Perform straight catheterization every 4 hours Avoid drinking fluids for 6 hours Implement a 2- to 3-hour voiding schedule
Implement a 2- to 3-hour voiding schedule
Patients with urolithiasis need to be encouraged to: Participate in strenuous exercises so that the tone of smooth muscle in the urinary tract can be strengthened to help propel calculi. Supplement their diet with calcium needed to replace losses to renal calculi. Increase their fluid intake so that they can excrete 2.5 to 4 liters every day. Limit their voiding to every 6 to 8 hours so that increased volume can increase hydrostatic pressure, which will help push stones along the urinary system.
Increase their fluid intake so that they can excrete 2.5 to 4 liters every day
A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? It is the only device that can be applied for stabilization of a spinal fracture. It allows for stabilization of the cervical spine along with early ambulation. It is less bulky and traumatizing for the patient to use. The patient can remove it as needed.
It allows for stabilization of the cervical spine along with early ambulation.
What intervention is a priority for a client diagnosed with osteoarthritis? Allopurinol Physical therapy and exercise Hydrotherapy Colchicine
Physical therapy and exercise
A client with quadriplegia is in spinal shock. What finding should the nurse expect? Hyperreflexia along with spastic extremities Spasticity of all four extremities Absence of reflexes along with flaccid extremities Positive Babinski's reflex along with spastic extremities
Absence of reflexes along with flaccid extremities
The nurse is assessing the client's ileal conduit stoma in the clinic. Which assessment finding would be of greatest concern to the nurse? The skin surrounding the stoma is red. Yellow urine is draining from the stoma. The urine has an ammonia odor. The stoma is dusky red.
The stoma is dusky red.
While snowboarding, a fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? skull fracture laceration concussion contusion
concussion
Which finding is an early indicator of bladder cancer? Dysuria Occasional polyuria Painless hematuria Nocturia
Painless hematuria
The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of? Contusion Autonomic dysreflexia Concussion Spinal shock
Autonomic dysreflexia
You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? Autonomic dysreflexia Paraplegia Areflexia Tetraplegia
Autonomic dysreflexia
Which objective symptom of a UTI is most common in older adults, especially those with dementia? Back pain Change in cognitive functioning Hematuria Incontinence
Change in cognitive functioning
The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful? Adoption is an option to complete your family but not put your life in jeopardy. Sterilization is best; it would be difficult to care for a baby in your condition. Birth via surrogate is best because your baby can be implanted in another woman. Conception is not impaired; the birth process is determined with the physician.
Conception is not impaired; the birth process is determined with the physician.
A client was undergoing conservative treatment for a herniated nucleus pulposus, at L5 - S1, which was diagnosed by magnetic resonance imaging. Because of increasing neurologic symptoms, the client undergoes lumbar laminectomy. The nurse should take which step during the immediate postoperative period? Have the client sit up in a chair as much as possible. Elevate the head of the bed to 90 degrees. Discourage the client from doing any range-of-motion (ROM) exercises. Logroll the client from side to side.
Logroll the client from side to side.
A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do? Maintain a diet for the client that is high in protein, vitamins, and calories. Keep accurate intake and output. Watch closely for signs of urinary tract infection. Avoid range of motion exercises for the client because of spasms.
Maintain a diet for the client that is high in protein, vitamins, and calories.
A nurse is reviewing the history and physical examination of a client with a suspected malignant tumor of the bladder. Which finding would the nurse identify as the most common initial symptom? Painless hematuria Frequency Fever Urinary retention
Painless hematuria
The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation? Escape of cerebrospinal fluid from the client's ear A bloodstain surrounded by a yellowish stain on the head dressing An area of bruising over the mastoid bone Escape of cerebrospinal fluid from the client's nose
An area of bruising over the mastoid bone
Which condition is the leading cause of disability and pain in the elderly? Scleroderma Osteoarthritis (OA) Rheumatoid arthritis (RA) Systemic lupus erythematous (SLE)
Osteoarthritis (OA)
Which joint is most commonly affected in gout? Tarsal area Metatarsophalangeal Ankle Knee
Metatarsophalangeal
A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? Monitoring is needed as rapid neurologic deterioration may occur. The crash cart with defibrillator is kept nearby. Bleeding continues into the intracerebral area. Symptoms will evolve over a period of 1 week.
Monitoring is needed as rapid neurologic deterioration may occur.
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord? Creutzfeldt-Jakob disease Huntington disease Parkinson disease Multiple sclerosis
Multiple sclerosis
The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis? Muscle weakness and hyporeflexia of the lower extremities Fever and cough Hyporeflexia and skin rash Ptosis and muscle weakness of upper extremities
Muscle weakness and hyporeflexia of the lower extremities
