quiz 1 select all that apply

A nurse begins discharge planning for a rehabilitation patient who will be discharged in a wheel chair. Which would the nurse include in this predischarge assessment? (Select all that apply.)

-feelings and concerns related to discharge -doorway widths within the patients home -patients ability to perform all/iadl -support resources needed

A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) a. Consults with other disciplines on client care b. Coordinates discharge planning for home safety c. Participates in comprehensive client rounding d. Routinely asks other disciplines about client progress e. Shows the nursing care plans to other disciplines

A, B, C, D Response Feedback: Collaborating with the interdisciplinary team involves planning, implementing, and evaluating patient care as a team with all other involved disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating with them.

A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.) a. Ensure that an informed consent is present. b. Ask the client about any allergies .c. Evaluate the clients renal function. d. Auscultate bilateral breath sounds. e. Assess hematocrit and hemoglobin levels.

ANS: A, B, C A client who is scheduled to receive iodine-based contrast should be asked about allergies, especially allergies to iodine or shellfish. The clients kidney function should also be evaluated to determine if it is safe to administer contrast during the procedure. Finally, the nurse should ensure that an informed consent is present because all clients receiving iodine-based contrast must give consent. The CT will have no impact on the clients breath sounds or hematocrit and hemoglobin levels. Findings from these assessments will not influence the clients safety during the procedure.

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease

ANS: A, B, C Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which statements should the nurse include when delegating this clients care? (Select all that apply.) a. Plan to bathe the client in the evening when the client is most alert. b. Encourage the client to use a cane when ambulating. c. Assess the client for symptoms related to pain and discomfort. d. Remind the client to look at foot placement when walking. e. Schedule additional time for teaching about prescribed therapies.

ANS: A, B, D The nurse should tell the UAP to schedule activities when the client is normally awake, encourage the client to use a cane when ambulating, and remind the client to look where feet are placed when walking. The nurse should assess the client for symptoms of pain and should provide sufficient time for older adults to process information, including new teaching. These are not items the nurse can delegate.

A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Ipsilateral tearing of the eye b. Miosis c. Abrupt loss of consciousnessTest Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 361 d. Neck and shoulder tenderness e. Nasal congestion f. Exophthalmos

ANS: A, B, E Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and exophthalmos are not associated with cluster headaches.

An interdisciplinary team is caring for a client on a rehabilitation unit. Which team members are paired with the correct roles and responsibilities? (Select all that apply.) a. Speech-language pathologist Evaluates and retrains clients with swallowing problems b. Physical therapist Assists clients with ambulation and walker training c. Recreational therapist Assists physical therapists to complete rehabilitation therapy d. Vocational counselor Works with clients who have experienced head injuriesTest Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 43 e. Registered dietitian Develops client-specific diets to ensure client needs are met

ANS: A, B, E Speech-language pathologists evaluate and retrain clients with speech, language, or swallowing problems. Physical therapists help clients to achieve self-management by focusing on gross mobility. Registered dietitians develop client-specific diets to ensure that clients meet their needs for nutrition. Recreational therapists work to help clients continue or develop hobbies or interests. Vocational counselors assist with job placement, training, or further education.

A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Diminished cognition

ANS: A, B, E The nurse should urgently communicate changes in a clients neurologic status, including a decrease in the Glasgow Coma Scale score, abnormal flexion or extension, changes in cognition or speech, and pinpointed, dilated, and nonreactive pupils.

A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.) a. Sodium level b. Liver enzymes c. Clotting factors d. Cardiac enzymes e. Creatinine level

ANS: A, C Inflammation associated with meningitis can stimulate the hypothalamus and result in excessive production of antidiuretic hormone. The nurse should monitor sodium levels for early identification of syndrome of inappropriate antidiuretic hormone. A systemic inflammatory response (SIR) can also occur with meningitis. A SIR can result in a coagulopathy that leads to disseminated intravascular coagulation. The nurse should monitor clotting factors to identify this complication. The other laboratory values are not specific to complications of meningitis.

A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells

ANS: A, C, D In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball. For which clinical manifestations that are related to a temporal lobe injury should the nurse assess? (Select all that apply.) a. Memory loss b. Personality changes c. Difficulty with sound interpretation d. Speech difficulties e. Impaired taste

ANS: A, C, D Wernickes area (language area) is located in the temporal lobe and enables the processing of words into coherent thought as well as the understanding of written or spoken words. The temporal lobe also is responsible for the auditory centers interpretation of sound and complicated memory patterns. Personality changes are related to frontal lobe injury. Impaired taste is associated with injury to the parietal lobe.

The nurse is caring for a client in late-stage Alzheimer disease. Which assessment finding(s) will the nurse anticipate? (Select all that apply.) a. Immobile b. Has difficulty driving c. Wandering d. ADL dependent e. Incontinent f. Possible seizures

ANS: A, D, E, F The client in late-stage Alzheimer disease is totally bedridden and immobile, and therefore, cannot ambulate to wander or drive. The client is incontinent and ADL dependent.

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids.Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 360 d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

ANS: A, D, F Oxygen and suctioning equipment with an airway must be readily available. The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client during a seizure and should not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The client should be encouraged to eat a well-balanced diet and ambulate while in the hospital.

A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication? a. Serum electrolyte levels b. Kidney function tests c. Complete blood cell count d. Antinuclear antibodies

ANS: B Adverse effects of levetiracetam include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)

ANS: B Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.

After administering a medication that stimulates the sympathetic division of the autonomic nervous system, the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Decreased respiratory rate b. Increased heart rate c. Decreased level of consciousness d. Increased force of contraction e. Decreased blood pressure

ANS: B, D Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart rate and the force of contraction. A medication that stimulates the sympathetic nervous system would also increase the clients respiratory rate, blood pressure, and level of consciousness.

A rehabilitation nurse is caring for an older adult client who states, I tire easily. How should the nurse respond? (Select all that apply.) a. Schedule all of your tasks for the morning when you have the most energy. b. Use a cart to push your belongings instead of carrying them. c. Your family should hire someone who can assist you with daily chores d. Plan to gather all of the supplies needed for a chore prior to starting the activity e. Try to break large activities into smaller parts to allow rest periods between activities.

ANS: B, D, E A cart is useful because it takes less energy to push items than to carry them. Gathering equipment before performing a chore decreases unneeded steps. Breaking larger chores into smaller ones allows rest periods between activities and still gives the client a sense of completion even if the client is unable to complete the whole task. Major tasks should be performed in the morning, when energy levels are high, while lesser tasks should be done throughout the day after frequent rest periods. Someone should be hired to do the chores only if the client cannot do them. The outcome should be achieving independence as close to the pre-disability level as possible.

chapter 41 A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Loss of smell b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex

ANS: B, D, E Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.

A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.) a. Photophobia b. Dilated pupils c. Headache d. Widened pulse pressureTest Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 363 e. Bradycardia

ANS: B, D, E Increased ICP is a complication of encephalitis. The nurse should monitor for signs of increased ICP, including dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are not related to increased ICP.

A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this clients plan of care? (Select all that apply.) a. Increase your intake of caffeinated beverages. b. Incorporate physical exercise into your daily routine. c. Avoid all alcoholic beverages. d. Participate in a smoking cessation program. e. Increase your intake of fruits and vegetables.

ANS: B, D, E Triggers for headaches include caffeine, smoking, and ingestion of pickled foods, so these factors should be avoided. Clients are taught to eat a balanced diet and to get adequate exercise and rest. Alcohol does not trigger chronic headaches but can enhance headaches during the headache period.

A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.) a. Long-term memory loss b. Slower processing time c. Increased sensory perception d. Decreased risk for infection e. Change in sleep patterns

ANS: B, E Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination.

A nurse is caring for clients as a member of the rehabilitation team. Which activities should the nurse complete as part of the nurses role? (Select all that apply.) a. Maintain the safety of adaptive devices by monitoring their function and making repairs. b. Coordinate rehabilitation team activities to ensure implementation of the plan of care. c. Assist clients to identify support services and resources for the coordination of services. d. Counsel clients and family members on strategies to cope with disability. e. Support the clients choices by acting as an advocate for the client and family.

ANS: B, E The rehabilitation nurses role includes coordination of rehabilitation activities to ensure the clients plan of care is effectively implemented and advocating for the client and family. The biomedical technician monitors and repairs adaptive and electronic devices. The social worker assists clients with support services and resources. The clinical psychologist counsels clients and families on their psychological problems and on strategies to cope with disability.

Chapter 6 A nurse collaborates with an occupational therapist when providing care for a rehabilitation client. With which activities should the occupational therapist assist the client? (Select all that apply.) a. Achieving mobility b. Attaining independence with dressing c. Using a walker in public d. Learning techniques for transferring e. Performing activities of daily living (ADLs) f. Completing job training

ANS: B, E The role of the occupational therapist is to assist the client with ADLs, dressing, and activities needed for job training. The physical therapist assists with muscle strength development and ambulation. Vocational counselors assist with job placement, training, and further education.

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Intermittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at clothing f. Patting of the hand on the leg

ANS: B, E, F Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.

A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures

ANS: C, D Complications of surgery to implant a vagal nerve stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures. Bleeding is not a common complication of this procedure, and infection would not occur during the recovery period.

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment should the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves

ANS: D, E Meningeal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? a. Assesses for cultural influences affecting health careb. Ensures that all the clients' basic needs are metc. Tells the client and family about all upcoming testsd. Thoroughly orients the client and family to the room

a. Assesses for cultural influences affecting health care

A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes which components? (Select all that apply.) a. Dementia b. Exhaustion c. Slowed physical activity d. Weakness e. Weight gain

b. Exhaustion c. Slowed physical activity d. Weakness Response Feedback: Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this cluster of manifestations.