661 Final Exam Review Questions

A terminally ill patient has just died in a hospital setting with family members at the bedside. The health care provider is also present. What should be the nurse's priority intervention as postmortem care begins? A. Call for emergency assistance so that resuscitation procedures can begin. B. Ask family members if they would like to spend time alone with the patient. C. Ensure that a death certificate has been completed by the physician. D. Request family members to prepare the patient's body for the funeral home.

B. Ask family members if they would like to spend time alone with the patient. The first priority in post-mortem care is to address the family and their needs; allowing them as much time with the patient as they need. Resuscitation measures will not ensue following death of a terminally ill patient. Family does not prepare the body for the funeral home, although some cultures will participate in postmortem care. The death certificate is not the priority.

A patient with trigeminal neuralgia asks the nurse for a snack and something to drink. Which of the following selections should the nurse provide for the patient? A. Hot cocoa with honey and toast B. Vanilla wafers and lukewarm milk C. Hot herbal tea with graham crackers D. Iced coffee and peanut butter crackers

B. Vanilla wafers and lukewarm milk Because mild tactile simulation of the face can trigger pain, the patient needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.

A patient diagnosed with leukemia asks the nurse questions about preparing a living will. The nurse informs the patient that the best method of preparing this document is to: A. Talk to the hospital chaplain B. Obtain advice from an attorney C. Discuss the request with the provider D. Consult the American Cancer Society

C. Discuss the request with the provider Living wills are legal documents known as advanced directives wherein the patient delineates the withdrawal or withholding of treatment when the patient is incompetent; it should not be confused with a will that bequeaths personal property and specifies other actions at the time of the patient's death. The patient starts the process of writing a living will by discussing treatment options and other related issues with the provider. Although hospital chaplain and attorney would be helpful, contacting them is not the initial step because both professionals lack the medical information the patient needs to make the informed decision. The American Cancer Society will not have information individualized to the patient's needs.

Mannitol is administered intravenously to a patient admitted to the hospital with loss of consciousness and a closed head injury. The nurse determines that the medication has achieved its priority effect if which of the following outcomes is noted? A. Weight loss of 1kg and serum creatinine of 0.8 mg/dL B. Serum creatinine of 1.2 mg/dL and normal intracranial pressure C. Improved level of consciousness and normal intracranial pressure D. Diuresis of 500mL in 2 hours and a BUN of 15 mg/dL

C. Improved level of consciousness and normal intracranial pressure Mannitol is an osmotic diuretic that can administered parenterally to treat cerebral edema. Lowering of intracranial pressure occurs within 15 minutes of administration and diuresis occurs within 1 to 3 hours. Expected effects of the medication include rapid diuresis and fluid loss. For the patient with cerebral edema, effectiveness is measured by assessing level of consciousness/neurological status and intracranial pressure readings.

The nurse is planning care for a patient with a T3 spinal cord injury. The nurse includes which intervention in the plan to prevent autonomic hyperreflexia? A. Administer dexamethasone as per the provider's order B. Assess vital signs and observe for hypotension, tachycardia, and tachypnea C. Teach the patient that this condition is relatively minor with few symptoms D. Assist the patient to develop a daily bowel routine to prevent constipation

D. Assist the patient to develop a daily bowel routine to prevent constipation Autonomic hyperreflexia is a potentially life-threatening condition that may be triggered by bladder or bowel distention, visceral distention, or stimulation of pain receptors on the skin. A daily bowel regimen program eliminates this trigger. A patient with autonomic hyperreflexia would be hypertensive and bradycardic. Removal of stimuli results in prompt resolution of signs and symptoms. Dexamethasone is unrelated to this specific condition.

A nurse is assessing a patient's extraocular eye movements as part of evaluating neurological functioning. Which cranial nerve status is documented? (Select all that apply.) a. Optic (II) b. Oculomotor (III) c. Trochlear (IV) d. Trigeminal (V) e. Abducens (VI) f. Acoustic (VIII)

b, c, e b. Oculomotor (III) c. Trochlear (IV) e. Abducens (VI) Assessing extraocular eye movements helps evaluate the function of cranial nerves III, IV, and VI. Optic (II) evaluates pupillary function. Trigeminal (V) evaluates sensation and motor function of the three branches of the nerve that innervate corneal reflex and sensation of the upper and lower aspects of the face. Acoustic (VIII) evaluates hearing and balance.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? A. Face the client and establish eye contact B. Talk in louder than normal voice C. Keep the television on while nurse speaks D. Use on long sentence to say everything that needs to be said

A. Face the client and establish eye contact

The nurse is caring for a client who is considering being admitted to hospice. What is the nurse's best response? A. "Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge." B. "Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms." C. "Hospice care will not help with your symptoms of depression. I will refer you to the facility's counseling services instead." D. "You seem to be experiencing some difficulty with this stage of the grieving process. Let's talk about your feelings."

B. "Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms." Hospice is a holistic approach aimed at increasing comfort at the end of life. While there are some criteria for hospice, option A is not a therapeutic response by the nurse and does not address the patient's interest in hospice. Hospice can help with depression symptoms and treatment as a way to aid in comfort. There is no data in the question to alert the nurse to difficulty with grieving.

Which medication is the most effective agent in the treatment of Parkinson disease? A. Amantadine B. Levodopa C. Bromocriptine mesylate D. Benztropine

B. Levodopa

A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified? A. Advanced age B. Gender C. Ethnicity D. Hypertension

D. Hypertension

A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client? A. Write down any adverse drug effects B. Start client on 12L/min O2 for 15-20 min C. When attack occurs, stay in brightly lit area D. Identify and avoid factors that precipitate or intensify attack

D. Identify and avoid factors that precipitate or intensify attack

The most common treatment of pain in a terminally ill patient is administration of which kind of therapy? A. Opioids B. Steroids C. Nonsteroidal Anti-inflammatory agents (NSAIDs) D. Acetaminophen

A. Opioids

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: A. Kernig's Sign B. Positive edrophonium (Tensilon) test C. Positive seat chloride test D. Brudzinski's sign

B. Positive edrophonium (Tensilon) test

The nurse is assessing the dying patient. Which manifestations of a dying patient should the nurse assess to determine whether the patient is near death? A. Loss of appetite B. Respirations C. Bowel sounds D. Pain level on a 0 to 10 scale

B. Respirations

A patient is being brought to the emergency department after suffering a head injury. The first action by the nurse is to determine the patient's: A. Level of consciousness B. Pulse and blood pressure C. Respiratory rate and depth D. Ability to move extremities

C. Respiratory rate and depth The first action of the nurse is to ensure that the patient has an adequate airway and respiratory status. In rapid sequence, the patient's circulatory status is evaluated, followed by neurological status.

The nurse is caring for a patient admitted to the hospital after sustaining a head injury. In which position should the nurse place the patient to prevent increasing intracranial pressure (ICP)? A. Left Sim's position B. Reverse Trendelenburg C. With the head elevated on a pillow D. With the head of the bed elevated at least 30 degrees

D. With the head of the bed elevated at least 30 degrees The patient with a head injury is positioned to avoid extreme flexion or extension of the neck and to maintain the head in the midline, neutral position. Elevation of the HOB at least 30 degrees will enhance venous drainage, which helps prevent increased ICP.

The nurse is providing care for a dying patient. The nurse would place highest priority on treating which symptoms? (Select all that apply.) a. Weight loss b. Pain c. Agitation d. Drowsiness e. Dyspnea

b, c, e b. Pain c. Agitation e. Dyspnea

As the nurse admits a patient in end-stage kidney disease to the hospital, the patient tells the nurse, 'If my heart or breathing stop, I do not want to be resuscitated.' Which action is best for the nurse to take? A. Ask if these wishes have been discussed with the health care provider and if a MOLST form has been filled out. B. Place a 'Do Not Resuscitate' (DNR) notation in the patient's care plan. C. Inform the patient that a notarized advance directive must be included in the record or resuscitation must be performed. D. Advise the patient to designate a person to make health care decisions when the patient is not able to make them independently.

A. Ask if these wishes have been discussed with the health care provider and if a MOLST form has been filled out.

Which action is best for the nurse to take to ensure culturally competent care for an alert, terminally ill Filipino patient? A. Ask the patient and family about their preferences for care during this time. B. Let the family decide whether to tell the patient about the terminal diagnosis. C. Obtain information from Filipino staff members about possible cultural needs. D. Remind family members that dying patients prefer to have someone at the bedside.

A. Ask the patient and family about their preferences for care during this time.

A client the nurse is caring for experiences a seizure. What would be a priority nursing action? A. Protect client from injury B. Insert tongue blade between teeth C. Suction mouth during convulsion D. Restrain client during seizure

A. Protect client from injury

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? A. Turn client to side-lying position B. Monitor vital signs C. Manually restrain the extremities D. Insert an airway or bite block

A. Turn client to side-lying position

The terminally ill client is prescribed morphine to cope with increasing discomfort. A family member expresses concern that the client is on "too much morphine." What is the nurse's best response? A. "What has the physician told you about your family member's illness?" B. "Don't worry about that. We're following the physician's plan of care." C. "Tell me more about what you mean by too much morphine." D. "You should talk with your physician about this when he makes rounds."

C. "Tell me more about what you mean by too much morphine." The nurse should investigate as to why the family feels the patient is receiving too much morphine and address specific concerns and help to educate the family regarding pain management and pain at the end of life. Asking about the illness does not address the main concern about the morphine dose. The nurse should not refer to the physician, as he/she can address this concern first. The nurse should not dismiss the family's concerns.

The home care nurse is assisting a patient in managing cancer pain. To ensure that the client has adequate and safe pain control, the nurse plans to: A. Rely totally on prescription and other-the-counter medications to relieve pain B. Keep a baseline level of pain so that the client does not become sedated C. Try multiple medication modalities for pain relief to get the maximum pain relief effect D. Start with low doses of medication and gradually increase to a dose that relieves pain, not exceeding the maximum daily dose

D. Start with low doses of medication and gradually increase to a dose that relieves pain, not exceeding the maximum daily dose Safe pain control includes starting low and working up to a dose that relieves pain. Multiple medication modalities can be unsafe and ineffective. There are other interventions that can be utilized to relieve pain. Maintaining a baseline level of pain to avoid sedation is not appropriate practice, unless the patient requests this.

A nurse is comparing the neurological status of a patient who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the patient's score has changed from 11 to 15. Which of the following responses did the nurse assess in the patient? (Select all that apply.) a. Spontaneous eye opening b. Tachypnea, bradycardia, and hypotension c. Unequal pupil size d. Orientation to person, place, and time e. Pain localization f. Incomprehensible sounds

a, d a. Spontaneous eye opening d. Orientation to person, place, and time The Glasgow Coma Scale (GCS) is a tool to assess a patient's response to stimuli. To achieve a perfect score of 15, the patient would have to open his eyes spontaneously (4 points), obey verbal commands (6 points), and be oriented to person, place, and time (5 points). Vital signs and pupil size are not assessed with the GCS. The ability to localize pain earns a motor response score of 5, not the top score of 6. Making incomprehensible sounds earns a verbal response score of 2, not a 5.