Test 3

The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells you that he has been reading a lot about strokes and asks why his wife had not received alteplase (Activase). Which of the following would be the best response by the nurse?

Alteplase dissolves clots and may cause more bleeding into your wife's brain

A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching?

"I will reduce my intake of vitamin K-rich foods."

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?

"Implement a schedule to include periods of rest"

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

"Incorporate nonverbal cues in the conversation."

The nurse is teaching the daughter of a client who has middle stage Alzheimer's disease. The daughter asks, "Will the sertraline my mother is taking improve her dementia?" Which of the following would be the best response by the nurse?

"It will not improve her Alzheimer's disease, but can help control her emotional responses."

A nurse is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan of care? (select all that apply)

- allow the client to assist with ADLs - talk the client through tasks one step at a time

A patient with varicella zoster has a complication of dehydration. Which of the following actions should the nurse take? (select all that apply)

- assure assigned nurse has a positive immune status - explain guidelines for contact precautions to family - place in a negative air flow room

A nurse is teaching a client who is taking benztropine (Cogentin) to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects? (Select all that apply)

- difficulty voiding - constipation

A nurse is preparing to teach a client with a new diagnosis of osteoporosis about strategies to prevent falls. Which of the following teaching points should the nurse include in the teaching? (select all that apply)

- exercise to help build your strength - rest when you are tired and fatigued - wear a hip protector when ambulating - remove throw rugs and other obstacles at home

The nurse is caring for a patient with a cast recently applied for a fractured tibia. Which assessment findings indicate possible compartment syndrome? (Select all that apply)

- inability to move extremity - tingling of extremity - severe pain not relieved by analgesics

A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following adverse effects should the nurse instruct the client to report to the provider? (select all that apply)

- jaw pain - dysphagia - blurred vision

A nurse is assessing a patient who has puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis? (select all that apply)

- localized erythema - tachycardia

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? (select all that apply)

- provide client supervision - encourage exercise alternating with periods of rest

A nurse is teaching a client who has psoriasis about possible treatment options. Which of the following treatments should the nurse include in the teaching? (select all that apply)

- tar treatments - ultraviolet light - corticosteroids

The nurse is assessing a lesion in a patient with psoriasis. Which information should the nurse obtain from this patient? (select all that apply)

- time of disease onset - presence of itching - description of disease progression

The physician orders morphine 15 mg intravenous piggyback now for a patient with a femoral fracture. You have available morphine 10 mg/mL. Which of the following dosages is the correct dosage to give the adolescent?

1.5 mL

A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching?

Dry the prosthesis socket completely before applying it to the limb

The nurse cares for a client with middle stage Alzheimer's disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" Which of the following would be the best response by the nurse?

Engage the client in scheduled activities throughout the day

A nurse is caring for a client who is 3 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take?

Have the patient lie prone several times per day

The nurse is teaching a family caregiver about how to best communicate with a client diagnosed with Alzheimer's disease. Which statement by the caregiver indicates a need for further teaching?

I will avoid communicating with the client to prevent agitation

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

Kyphosis

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client?

Levodopa/carbidopa

A nurse is caring for a client who has has a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Manifestations preceded by a severe headache

Three days after the application of a cast a patient has a temperature of 101.4 F. Suspecting an infection, what clinical finding does the nurse anticipate?

a foul odor from the cast

A nurse in a long-term care facility is caring for an older adult who had a stroke four weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

a reddened area over the sacrum

A nurse is planning care for an older adult who has varicella zoster. Which of the following interventions should the nurse include in the plan of care?

administer analgesics for pain

A nurse is caring for a patient who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

administer antibiotics to the patient

A client with a right arm cast for a fractured humerus states, "I haven't been able to straighten my fingers on my right side since this morning." What action should the nurse take FIRST?

assess neurovascular status to the hand

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

bradykinesia

A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make?

brisk walking

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

comminuted

A patient is to receive intravenous antibiotics for osteomyelitis. Before the initial dose of antibiotics can be given, the nurse confirms that a blood sample for which of the following tests has been drawn?

culture

A nurse is teaching a patient who has multiple sclerosis about a new prescriptions for baclofen. Which of the following instructions should the nurse include in the teaching?

do not take antihistamines with this medication

A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan of care?

elevate the leg of two pillows

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

encourage the client to take small bites

Which part of the body is LEAST likely to be affected by psoriasis?

face

A nurse is caring for a client who has multiple long bone fractures caused by a motor-vehicle crash that happened 24 hr ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications?

fat embolism syndrome

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?

intellectual impairment

A patient has undergone a below the knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the patient to notify the healthcare provider if which of the following changes occur?

observation of a large amount of serosanguinous or blood drainage from the stump

A patient who has severe peripheral vascular disease resulting in an above the knee amputation two months ago describes intense burning pain, numbness and tingling in the limb. The patient reports the symptoms worsen with exhaustion and stress. What is the patient most likely experiencing?

phantom limb pain

A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication?

pitting edema around the stump dressing

A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings?

silvery, white scales

A nurse is caring for a client following a stroke observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

supplements via nasogastric tube

The nurse is conducting an assessment on a client who has fractures of the medial ulna and radius. Which of the following assessment findings should the nurse report to the healthcare provider immediately?

the patient reports pressure and pain

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following information should the nurse include in the plan?

use bath oils to soften and soothe the skin