Week 7 PrepU

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. - Assess the client who is at risk for shock. - Administer vasoconstrictive medications to clients at risk for shock. - Administer prophylactic packed red blood cells to clients at risk for shock. - Administer intravenous fluids. - Monitor for changes in vital signs.

- Assess the client who is at risk for shock. - Administer intravenous fluids. - Monitor for changes in vital signs.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. What is the origin of the client's symptoms? - impaired cerebral circulation - cardiac disease - diabetes insipidus - hypertension

impaired cerebral circulation

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? - liver dysfunction - organ damage - weight loss - unsteady gait

organ damage

When communicating with a client who has sensory (receptive) aphasia, the nurse should: - allow time for the client to respond. - speak loudly and articulate clearly. - give the client a writing pad. - use short, simple sentences.

use short, simple sentences.

The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion? - The client is in the compensatory stage of shock. - The client is in the progressive stage of shock. - The client will stabilize and be released by tomorrow. - The client is in the irreversible stage of shock.

The client is in the compensatory stage of shock.

The nurse in the ED is caring for a client recently admitted with a likely myocardial infarction. The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess? - Dysrhythmias - Increase in blood pressure - Increase in heart rate - Decrease in oxygen demands

Dysrhythmias

A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. - Left-sided hemiplegia - Tendency to distractibility - Impairment of long-term memory - Hyperaware of deficits - Neglect of objects and people on the left side

- Left-sided hemiplegia - Tendency to distractibility - Neglect of objects and people on the left side

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? - Bleeding - Headache - Increased intracranial pressure (ICP) - Hypertension

Bleeding

You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock? - Circulatory (distributive) - Cardiogenic - Hypovolemic - Obstructive

Circulatory (distributive)

The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by: - Cold, clammy skin and tachycardia. - A systolic blood pressure of 75 mm Hg. - A heart rate of 140. - Crackles and shallow breathing.

Cold, clammy skin and tachycardia.

Which statement reflects nursing management of the client with expressive aphasia? - Encourage the client to repeat sounds of the alphabet - Speak clearly to the client in simple sentences, and use gestures or pictures when able - Speak slowly and clearly to assist the client in forming the sounds - Frequently reorient the client to time, place, and situation

Encourage the client to repeat sounds of the alphabet

In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances? - Fluid volume circulating in the blood vessels decreases. - There is an uncontrolled increase in cardiac output. - Blood pressure regulation becomes irregular. - The client experiences tachycardia and a bounding pulse.

Fluid volume circulating in the blood vessels decreases.

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke? - Intracerebral hemorrhage - Subarachnoid hemorrhage - Hemorrhage due to an aneurysm - Arteriovenous malformation

Intracerebral hemorrhage

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: - Weakness on one side of the body and difficulty with speech - Severe headache and early change in level of consciousness - Foot drop and external hip rotation - Confusion or change in mental status

Severe headache and early change in level of consciousness

The nurse is caring for a client whose worsening infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock? - Elevated systolic blood pressure - Elevated mean arterial pressure (MAP) - Shallow, rapid respirations - Bradycardia

Shallow, rapid respirations

Which statements reflect the nursing management of a client with receptive aphasia? - Encourage the client to repeat sounds of the alphabet. - Speak clearly to the client in simple sentences; use gestures or pictures. - Speak slowly and clearly to assist the client in forming the sounds. - Frequently reorient the client to time, place, and situation.

Speak slowly and clearly to assist the client in forming the sounds.

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? - Weakness on one side of the body and difficulty with speech - Severe headache and early change in level of consciousness - Foot drop and external hip rotation - Vomiting and seizures

Weakness on one side of the body and difficulty with speech

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply. - Vital signs - Nutrition - Skin color - Gait - Urine output - Peripheral pulses

- Vital signs - Skin color - Urine output - Peripheral pulses

Which of the following, if left untreated, can lead to an ischemic stroke? - Atrial fibrillation - Cerebral aneurysm - Arteriovenous malformation (AVM) - Ruptured cerebral arteries

Atrial fibrillation

The nurse has just received report on a client in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which findings does the nurse understand is indicative of a right hemispheric stroke? - Aphasia - Spatial-perceptual deficits - Slow, cautious behavior - Altered intellectual ability

Spatial-perceptual deficits