Unit 5 quiz
A nurse is performing a neuro assessment for a client with head trauma. Which of the following will give the nurse info on CNIII?
Ask the client to move their eyes up and down without moving their head
A nurse is caring for a client who has quadriplegia from SCI and reports having a severe headache. The BP is 210/108. Which of the following actions should the nurse take first?
Assess for bladder distention.
A nurse is assessing a client who has lupus and is prescribed hydroxychloroquine. Which of the following adverse effects should the nurse report to the provider immediately?
Blurred vision
This type of SCI the patient develops motor weakness/paralysis on one side of the body and sensory loss on the other side of the body below the level of injury.
Brown-Sequard syndrome
A nurse is assessing a client who has SLE. Which of the following findings should the nurse expect?
Butterfly rash
A nurse is caring for a client who has HIV. Which of the following lab values is the nurse's priority?
CD4 of 180
A nurse is caring for a pregnant patient who has bipolar disorder. She asks about the safety of taking lithium while breastfeeding. Which of the following statements is most appropriate for the nurse?
Discuss this with your healthcare provider.
1. A nurse is presenting education about HIV/AIDS. A client asks the nurse to describe the initial symptoms of HIV infection.
Flu-like symptoms
A client who has just received organ transplant is receiving prednisone. The nurse is completing discharge education and determines learning has not occurred when the patient makes which of the following statements?
I will monitor for signs of hypoglycemia. (will be looking for signs of hyperglycemia)
A nurse is caring for a client who is experiencing cushing triad following subdural hematoma. Which of the following meds should the nurse expect to administer?
Mannitol
A nurse is assessing a client who is 2 weeks post-op following a kidney transplant. Which of the following manifestations should the nurse ID as possible organ rejection?
Oliguria
A nurse is caring for a child who is post op following ventriculoperitoneal shunt placement. Which of the following positions should the nurse place the client?
Semi-fowlers
1. A nurse is caring for a client who sustained a basal skull fracture and notices a thin stream of clear drainage coming from right nostril. Which of the following actions should the nurse take?
Test the drainage for glucose
A nurse is caring for a child having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
Turn patient on their side.
A nurse is talking to the client who has come to the clinic for HIV testing. The nurse explains that after the lab has the ELISA test results, it will use which of the following test to confirm the diagnosis?
Western blot test
A nurse is caring for a client with schizophrenia. They are in the _____ phase as evidenced by the presence of _______.
a. Active b. Positive symptoms
Caring for a patient in the manic phase of bipolar. Which of the following actions should the nurse take? a. Ask client which foods they prefer to eat b. Request prescription for NG tube c. Educate on pharm therapy d. Have high-protein, high-calorie snacks and finger foods e. Have high-calorie drinks like juice and soda f. Prevent them from taking naps through the day g. Encourage relaxation exercises before bed
a. Ask client which foods they prefer to eat c. Educate on pharm therapy d. Have high-protein, high-calorie snacks and finger foods g. Encourage relaxation exercises before bed
A nurse is caring for a client who sustained a TBI. The nurse should monitor the client for which of the following manifestations of IICP? a. Decreased LOC b. Tachypnea c. Bilateral weakness d. Hypotension
a. Decreased LOC
A nurse is caring for a patient with schizophrenia who is taking fluphenazine. Which of the following adverse effects should the nurse report to the doctor immediately? a. Muscle stiffness/spasm b. Orthostatic hypotension c. Sunburn after exposure d. Excess salivation
a. Muscle stiffness/spasm - extrapyramidal symptoms
A nurse is preparing to administer phenytoin IVP to a client with a seizure disorder. Which of the following actions should the nurse plan to take? a. Admin 100 mg/min b. Flush with saline following administration c. Mix with 50% dextrose d. Hold the injection if seizure activity is present
b. Flush with saline following administration
A 7-mo old infant demonstrates signs of IICP. The provider prescribes mannitol. Which of the following findings shows that therapy needs to continue? SATA a. Decrease in vomiting b. Sunsetting eyes c. Further reduction of heart rate d. Decreased LOC e. Increased RR
b. Sunsetting eyes c. Further reduction of heart rate d. Decreased LOC
A nurse is assessing a client who has lupus. Which of the following findings is the highest priority for the nurse to report to the provider? a. Feelings of depression b. Dry raised rash on face c. Peripheral edema d. Joint pain in hands
c. Peripheral edema - kidney involvement
A nurse is caring for a client who has HIV and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for which of the following adverse effects? a. Cardiac dysrhythmia b. Metabolic alkalosis c. Renal failure d. Aplastic anemia
d. Aplastic anemia
A nurse is performing discharge teaching for a client who has seizures and a new prescription of phenytoin. Which of the following means they need further teaching? a. I will notify my doctor before taking any new medications b. I have dentist appt next week c. I know that I cannot switch brands of the med d. I'll be glad when I can stop taking this med
d. I'll be glad when I can stop taking this med - it's a lifelong therapy
