Quiz questions

What risk factor is the most serious to address to prevent a recurrent hemorrhage? a. Weight b. Age c. Gender d. Hypertension

d. Hypertension

Often times brain attack (stroke) patients spend time in the ICU or Intermediate Care Unit. Once stabilized, they are transferred to the medical or neuro unit. Sometimes patients have paralysis, facial drooping, aphasia, and dysphagia. It is common practice to leave a IV saline lock in place as well as a urinary (Foley) catheter. Other than bedrest, the healthcare provider often recommends that the patient sit up in a chair four times a day. What nursing diagnosis would have the highest priority? a. Impaired physical mobility b. Self-care deficit c. Impaired social interaction d. Impaired swallowing (risk for aspiration)

d. Impaired swallowing (risk for aspiration)

A patient has been diagnosed with an ischemic left-sided brain attack (stroke). The neurologist determines that the patient is not a candidate for tissue plasminogen activator (tPA). Enoxaparin (Lovenox) is prescribed. 1 mg/kg subcutaneously every 12 hours. What intervention should the nurse include in the plan of care? a. Monitor the patient's INR daily b. Assess the patient's neurological status every shift c. Evaluate the patient's platelet levels daily d. Keep the head of the bed elevated.

d. Keep the head of the bed elevated.

You're providing education to a patient with severe ulcerative colitis about Adalimumab. Which statement by the patient is CORRECT? A. "This medication is used as first-line treatment for ulcerative colitis." B. "My physician will order a TB skin test before I start taking this medication." C. "This medication works by increasing the tumor necrosis factor protein which helps decrease inflammation." D. "This medication is a corticosteroid. Therefore, I need to monitor my blood glucose levels regularly."

B. "My physician will order a TB skin test before I start taking this medication."

Based on the information above, why would each of these medications be used? Nicardipine (Cardene) Mannitol Phenytoin (Dilantin)

C - To decrease systemic HTN M - To decrease cerebral edema D - To prevent seizures

You're providing teaching to a patient who has been newly diagnosed with Crohn's Disease. Which statement by the patient's spouse requires re-education? A. "Crohn's Disease can be scattered throughout the GI tract in patches with some areas appearing healthy while others are diseased." B. "There is no cure for Crohn's Disease." C. "Strictures are a common complication with Crohn's Disease." D. "Crohn's Disease can cause the large intestine to lose its form."

D. "Crohn's Disease can cause the large intestine to lose its form."

As one of your clinical assignments, you are assisting an RN with health screening at a health fair. Which individual is at greatest risk for experiencing a stroke? A. A 46-year-old white female with HTN and oral contraceptive use for 10 years. B. A 58-year-old white male salesman who has a total cholesterol level of 285 mg/dl. C. A 42-year-old African American female with DM who has smoked for 30 years. D. A 62-year-old African American male with HTN who is 35 pounds overweight.

D. A 62-year-old African American male with HTN who is 35 pounds overweight.

Identify some of the nonmodifiable risk factors for a stroke?

Family history Age Ethnicity

The nurse is teaching a patient and his spouse about preventing constipation. What interventions should be included in the teaching plan?

Increase physical activity Use stool softener Provide privacy Increase fluid intake High-fiber diet Regular bathroom time

What are the symptoms of a hemorrhagic stroke?

Severe headache Nausea Clinical manifestations of hemorrhagic stroke are similar to those of ischemic stroke. Diagnostic tests will help diagnose and differentiate

Which of the following statements is true regarding t-PA? a. "This medication will decrease the blood pressure b. "This medication will help dissolve clots." c. "This medication will prevent future strokes." d. "This medication will be changed to oral form in the future."

a. "This medication will decrease the blood pressure b. "This medication will help dissolve clots."

A nurse in an urgent care center is caring for a client who experienced an ankle injury. Prior to examination by the provider, which of the following nursing actions should the nurse perform? (Select all that apply.) a. Apply ice to the affected area. b. Encourage range of motion of the foot c. Provide the client with a light snack d. Apply a compression bandange e. Elevate the foot

a. Apply ice to the affected area. d. Apply a compression bandange e. Elevate the foot

After teaching a patient about dietary modifications, you determine that teaching was effective when they choose which menu? a. Baked cod, baked sweet potato, and canned pears. b. Barbecued brisket, coleslaw, baked beans, and angel food cake c. Fried shrimp with cocktail sauce, corn on the cob, and a fruit roll-up d. Turkey burger with cheese on a whole wheat bun, french fries, and an orange

a. Baked cod, baked sweet potato, and canned pears.

What additional clinical manifestation does the nurse expect to find if a patient symptoms have been caused by a brain attack (stroke)? a. Carotid bruit b. A hypotensive blood pressure c. Hyperreflexic deep tendon reflexes d. Decreased bowel sounds

a. Carotid bruit

A nurse in a medical clinic is providing teaching to an older adult client who has rheumatoid arthritis that is affecting her hands. Which of the following client statements indicates an understanding of the teaching? a. I can use either heat or ice to help relieve the discomfort." b. "Ibuprofen is the first step in medication therapy for rheumatoid arthritis" c. "I should limit physical activity to prevent physical injury. d. "I will elevate my legs by placing two pillows under my knees when I go to bed."

a. I can use either heat or ice to help relieve the discomfort." Answer Rationale: The nurse should instruct the client to avoid the use of pillows under the knees as this contributes to the development of flexion contractures.

Which intervention should the nurse implement while caring for with hemorrhagic stroke? a. Place the patient on strict bed rest b. Elevate the head of the bed 60 degrees c. Administer enemas to prevent constipation d. Encourage visitors to play games with the patient

a. Place the patient on strict bed rest

8. A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? a. Review the client's electrolyte values b. Check the client's perianal skin integrity c. Investigate the client's emotional concerns d. Obtain a dietary history from the client

a. Review the client's electrolyte values

Which of the following assessment findings would the nurse expect to find with a left hemisphere ischemic stroke? a. Right-sided paralysis b. Left-sided weakness c. Left homonymous hemianopsia d. Cautious behavior (this could also be correct as you would see - slow performance, cautious behavior, depression, anxiety, etc).

a. Right-sided paralysis d. Cautious behavior (this could also be correct as you would see - slow performance, cautious behavior, depression, anxiety, etc).

Which of the following factors constitute modifiable risk factors that to Stroke? a. Smoking b. Hypertension c. Diabetes d. Family history e. Obesity f. Age

a. Smoking b. Hypertension c. Diabetes e. Obesity

Which instructions should the nurse provide the patient when teaching him about an exercise program to improve mobility? Select all that apply. a. "You should practice walking long distances once or twice a daily." b. "Perform range of motion of your extremities four times each day." c. "You should not use a cane for mobility unless you are afraid of falling." d. "You should immediately report any chest pain or shortness of breath during activity." e. "You should keep a schedule to remind you to perform the prescribed exercises."

b. "Perform range of motion of your extremities four times each day." d. "You should immediately report any chest pain or shortness of breath during activity." e. "You should keep a schedule to remind you to perform the prescribed exercises."

A nurse is assessing a client following the application of a heating pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? a. Blistering b. Erythema c. Eschar d. Absence of pain

b. Erythema

What nursing intervention should the nurse implement when preparing a patient for a CT scan? a. Determine if the client has any allergies to iodine (only if ordered with contrast) b. Explain that the client will not be able to move his head throughout the CT scan. c. Premedicate the client to decrease pain prior to having the procedure d. Provide an explanation of relaxation exercises prior to the procedure

b. Explain that the client will not be able to move his head throughout the CT scan.

Which diet choice indicates that the patient understands the teaching on how diet can help prevent a recurrent stroke? a. Baked chicken, broccoli casserole, buttered roll, chocolate cake, and tea b. Roast turkey, plain baked potato, wheat roll, fruit cup, and tea. c. Chef salad with turkey, ham, cheese, bacon bits, and ranch dressing d. Plain hamburger, French fries, frozen yogurt, and milk

b. Roast turkey, plain baked potato, wheat roll, fruit cup, and tea.

6. A nurse in a provider's office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation of this condition? a. Anorexia b. Ulnar drift c. Low-grade fever d. Weight loss

b. Ulnar drift

A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication? a. "Take the medication between meals." b. "Take the medication with orange juice. c. "Take the medication with milk." d. "Take the medication on an empty stomach."

c. "Take the medication with milk."

Which nursing diagnosis is the priority? a. Risk for injury b. Anxiety c. Ineffective tissue perfusion d. Pain

c. Ineffective tissue perfusion

A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching? a. "I will sit on the side of the tub and soak my right leg two times every day." b. "I'll keep a heating pad on the calf of my right leg when I am lying down."c c. "I'll place my leg under a heat lamp every 3 hours." d. "I'll wrap a warm, wet towel around my right calf every 4 hours."

d. "I'll wrap a warm, wet towel around my right calf every 4 hours." Answer Rationale: Moist heat is more effective than dry heat in treating cellulitis. Moist heat relieves the manifestations of inflammation by increasing blood flow to the affected area. The nurse should instruct the client to elevate the right leg 8 to 15 cm (3 to 6 in) above the level of the heart and apply warm, moist heat to the site every 2 to 4 hr.

Which statement indicates t-PA has been effective? a. "The patient's vital signs are within normal limits b. "The patient has no signs or symptoms of bleeding." C. "The patient denies headache or dizziness." d. "The patient's neurologic function is improved."

d. "The patient's neurologic function is improved."

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication? a. White blood cell count (WBC) b. Rheumatoid factor c. Antinuclear antibody (ANA) d. Erythrocyte sedimentation rate (ESR)

d. Erythrocyte sedimentation rate (ESR) AR; Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases.