Acute Care Exam 3

Which diagnostic results does the nurse recognize that support the diagnosis of peptic ulcer disease (PUD)? (Select all that apply.) A. Low hemoglobin (Hgb) B. Low white blood cell (WBC) level C. Low hematocrit (Hct) D. Positive for H. pylori bacteria E. Low potassium of 3.4 mEq/L

A, C, D Low Hct and Hgb often occur related to bleeding. pt would have a high not low WBC, potassium is not diagnostic for PUD.

During a surgical procedure, the nurse notices the sponge count is incorrect. One sponge is missing. What is the priority nursing intervention? A. Communicate the discrepancy to the surgical team immediately. B. Complete appropriate documentation concerning the error in sponge count. C. Examine the environmental distractions, refocus, and count the sponges again. D. Anticipate that the surgeon will order an x-ray to look for the sponge postoperatively.

A Communicate the discrepancy to the surgical team immediately. -

The nurse is aware that a patient having surgery is at risk for infection if which additional factor is present? A.Diabetes mellitus B.Age greater than 65 C.Impaired liver function D.Insertion of a surgical drain

A Diabetes Mellitus -risk of infection is higher in patients with pre-existing health problems such as diabetes, immune deficiency, obesity, and kidney failure. -A surgical drain allows for the removal of secretions and fluids from within the tissues. Not having a drain could increase infection risk. Age increases risk-related skin injury from positioning and prolonged immobility during the procedure.

Ten days later the patient is to be discharged to a rehabilitation facility. The nurse understand which to be realistic initial priorities of care during rehabilitation? (Select all that apply.) A. Teaching self-care skills B. Working on mobility skills C. Bowel and bladder retraining D. Returning to pre-injury status E. Training caregivers to take over patient's care

A, B, C During rehab patients learn about self-care mobility, and work on bowel and bladder retraining a typical stay is 1-2 months, return to pre-injury status may not be realistic. The caregiver might need training at a later time, this is not the priority.

To ensure safe patient care transition from the perioperative nurse to the intraoperative nurse, optimal hand-off communication about the patient includes which elements? (Select all that apply.) A. Providing a recent patient history B. Communicating vital signs, allergy, and medication updates C. Verbally verifying that the operating room nurse understands the report D. Using a standardized hand-off communication tool to provide report (for example, SBAR, Five-Ps, PACE) E. Encouraging the operating room nurse to interrupt to ask questions as the perioperative nurse provides report

A, B, C, D,

Later in the afternoon, the patient states that the abdominal pain is getting worse. Which nursing interventions are appropriate? (Select all that apply.) A. Providing sitz baths as needed B. Administering analgesics as ordered C. Teaching music therapy or guided imagery D. Evaluating the diet for foods that cause pain E. Providing antidiarrheal medications if ordered

A, B, C, E Sitz bath will prevent skin excoriation, complementary therapies used in conjunction with analgesics can be very helpful in controlling pain. Antidirrheal medications may provide symptomatic relief. evaluating offending foods would not address the patients immediate symptom of pain.

Three days later, the patient is stable and the plan is to discharge her to home, where her mother will provide care for her. Which preparations are essential before discharge? (Select all that apply.) A.Arrange for special equipment in the home. B.Arrange for home modifications, such as a ramp. C.Teach the mother how to provide physical therapy. D.Teach family members how to use special equipment. E.Arrange for the patient to go to a rehabilitation facility before going home.

A, B, D. Before the PT goes home special equipment and modifications may need done. The family needs to know how to use the equipment. in home visits can be arranged for physical therapy. The patient is not required to go to rehab before going home.

A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 meter) fall. The nurse plans to assess the client for which potential complications? (Select all that apply.) A. Acute compartment syndrome (ACS) B. Fat embolism syndrome (FES) C. Congestive heart failure D. Urinary tract infection (UTI) E. Osteomyelitis

A, B, E

A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 meter) fall. The nurse plans to assess the client for which potential complications? A. Acute compartment syndrome (ACS) B. Fat embolism syndrome (FES) C. Congestive heart failure D. Urinary tract infection (UTI) E. Osteomyelitis

A, B, E ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures.Congestive heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

A fiberglass cast is applied to immobilize the ankle and allow for healing. Which nursing interventions are appropriate after the cast is applied? (Select all that apply.) A. Monitor for signs of infection. B. Assess peripheral capillary refill. C. Ask the patient if he will jog in the future. D. Keep the cast uncovered for air-drying over several hours. E. Insert a finger between the skin and the cast to be sure the cast is not too tight.

A, B, E Cast should dry within 10-15 mins. Not appropriate to ask about jogging.

As the patient prepares for discharge, the nurse provides education about behaviors that reduce symptoms and aggravate peptic ulcers. Which teaching does the nurse provide? (Select all that apply.) A. Sit upright 30 to 60 minutes after meals. B. Spices should be added to food to enhance flavor. C. Extreme vomiting should be reported to your physician. D. H. pylori can be a concern in patients with peptic ulcers. E. The goal of initial intervention is to control symptoms and prevent further complications.

A, C, D, E Patients should avoid spicy foods because they irritate the ulcer and gastric tissue. a vagotomy is associated with GI bleeds.

In conducting a postoperative assessment of a client, what is important for the nurse to examine first? A. Breathing pattern B. Level of consciousness C. Oxygen saturation D. Surgical site

A. Breathing pattern Respiratory assessment is the first and most important.Assessing level of consciousness, oxygen saturation, and the surgical site are important, but not the priority.

Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? A. Creatinine, 1.9 mg/dL (168 mcmol/L) B. Fasting glucose, 80 mg/dL (4.4 mmol/L) C. Potassium, 3.9 mEq/L (3.9 mmol/L) D. Sodium, 140 mEq/L (140 mmol/L)

A. Creatinine, 1.9 mg/dL (168 mcmol/L) The nurse will immediately report a creatinine of 1.9 mg/dL (168 mcmol/L) to the anesthesiologist. A creatinine of 1.9 mg/dL (168 mcmol/L) is outside the normal range and may indicate renal problems.A fasting glucose of 80 mg/dL (4.4 mmol/L), a potassium level of 3.9 mEq/L (3.9 mmol/L), and sodium level of 140 mEq/L (140 mmol/L) are normal laboratory values.

An older patient diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse should monitor the patient for what priority assessment? A. Dehydration B. Hypokalemia C. Hypernatremia D. Perineal skin breakdown

A. Dehydration. in older adults dehydration occurs with viral and bacterial Gasteroenteritis and may require hospitalization

The patient is admitted to the acute medical unit. Which medication would the nurse question? A. Ibuprofen (Motrin) B. Mesalamine (Asacol) C. Prednisone (Deltasone) D. Loperamide (Imodium)

A. Ibuprofen nonsteroidal anti-inflammatory drug NSAID increase the risk of bleeding.

A client sustains a fracture of one arm and the provider applies a plaster cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department? A. Monitor neuromuscular status for decreased circulation and sensation in the extremity. B. Apply a heating pad for 15 to 20 minutes four times daily to help with pain. C. Check the fit of the cast by inserting a tongue blade between the cast and the skin. D. Keep the cast covered with a soft towel to help it to dry quickly.

A. Monitor neuromuscular status for decreased circulation and sensation in the extremity. The most important intervention the nurse teaches the client is to monitor the neurovascular status during the first 24 hours after ED discharge.The client should apply ice for discomfort, not heat. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. To allow the cast to dry, it should remain uncovered.

To control the patient's pain, which order does the nurse anticipate will be given by the provider? A. Morphine 1 to 2 mg IV B. Meperidine 50 mg IM C. Acetaminophen 650 mg by mouth D. Apply ice packs to the right ankle

A. Morphine Acetominophene won't relieve pain 8/10. Meperidine isn't used anymore. Ice will help swelling not pain.

When the patient is asked about pain, he says that it is intense and continuous. He states that sometimes when he curls up in a fetal position the pain eases. Which medication does the nurse recognize that will provide the most comprehensive pain relief at this time? A. PCA morphine sulfate B. IM fentanyl (Sublimaze) C. PCA meperidine (Demerol) D. Oral hydromorphone (Dilaudid)

A. PCA morphine sulfate Meperidine is not a good choice because it can cause seizures especially in older adults. while hydromorphone is a good choice with acute pancreatitis pain, IV is best route.

An EGD confirms that the patient has PUD. Three hours later, the patient is admitted to the medical unit for workup and further testing. On admission the patient reports midline epigastric tenderness and indigestion (dyspepsia). The patient is prescribed triple therapy. Which drugs does the nurse prepare to administer? A.Proton pump inhibitor (PPI) and two antibiotics B.Antibiotic and two PPIs C.Histamine antagonist, antacid, and PPI D.Antacid, PPI, and prostaglandin analogue

A. Proton pump inhibitor For H. Pylori infections a common drug regimen is triple therapy which includesPPI such as lansoprazole, flatly, and clarithromycin, EGD.

The patient has been NPO but is now tolerating food. What education will the nurse provide regarding nutrition? A. Small and frequent meals are best. B. Use of alcohol and caffeine should be consumed in moderation. C. Expect to experience nausea and vomiting as you begin to consume foods. D. Low-carbohydrate, high-protein, and high-fat foods should be consumed.

A. Small and frequent meals are best. nausea and vomiting should not be expected, high carbs high protein and low fat foods should be included, alcohol and caffeine should be avoided.

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? A. Achieving the highest level of functioning B. Increasing cerebral perfusion C. Preventing further injury D. Preventing skin breakdown

ANS. A. Achieving the highest level of functioning The most important nurse's goal for the client with TBI is to help him or her achieve the highest level of functioning possible.The nurse assesses cerebral perfusion, such as oxygenation status, but cannot increase cerebral perfusion. Prevention of injury from falls, infection, or further impairment of cerebral perfusion is part of a larger goal for this client. Prevention of skin breakdown is a goal for the care of any client.

The nurse is caring for an older adult client who experiences an exacerbation of ulcerative colitis with severe diarrhea that have lasted a week. For which complications will the nurse assess? (Select all that apply.) a. Dehydration b. Hypokalemia c. Skin breakdown d. Deep vein thrombus e. Hyperkalemia

ANS: A, B, C The nurse will assess for complications such as dehydration, hypokalemia, and skin breakdown, all which can occur when diarrhea is profuse and fluid has been lost. Deep vein thrombosis and hyperkalemia are not complications that are associated with ulcerative colitis with severe diarrhea.

Which assessment findings will the nurse expect for the client with late-stage rheumatoid arthritis? (Select all that apply.) a. Bony nodes in finger joints b. Subcutaneous nodules c. Severe weight loss d. Joint deformity e. Thrombocytosis

ANS: A, B, C, D, E All of the choices are signs and symptoms of late rheumatoid arthritis which is a systemic and potentially joint-deforming disease as it progresses.

The nurse is caring for a client diagnosed with Guillain Barre syndrome. Which assessment findings require nursing action? (Select all that apply.) a. Blood pressure of 80/42 b. A respiratory rate of 24 c. Shallow breathing pattern d. A peripheral oxygen saturation (Spo2) of 85% e. Diminished breath sounds in all lung fields

ANS: A, C, D, E All choices except B are abnormal assessment findings that can occur in clients with this disease. A respiratory rate of 24 is slightly elevated but does not require nursing action.

The health care provider prescribes acetaminophen for a client with osteoarthritis. What health teaching will the nurse provide for this client regarding this drug? (Select all that apply.) a. "Don't take more than 3000-4000 mg of this drug each day." b. "Stop taking the drug if unusual bleeding occurs and call your health care provider." c. "Tell your health care provider if you notice any yellowing of your skin or eyes." d. "Expect fluid accumulation in your legs and feet that usually gets worse during the day." e. "Check over-the-counter drugs to see if they contain acetaminophen."

ANS: A, C, E The daily dosing of acetaminophen must be limited because it can cause liver toxicity and damage. Yellowing of skin or eye sclera can indicate liver damage.

A client had a left anterior total hip arthroplasty 2 days ago. Which precautions will the nurse teach the client to prevent surgical complications? (Select all that apply.) a. "Avoid extending your left hip behind you when you sit." b. "Do not flex your hips more than 90 degrees when toileting." c. "You may cross your legs to be more comfortable in a chair." d. "Avoid twisting your body when moving or performing ADLs." e. "Stand on your right leg and pivot into the chair when getting out of bed."

ANS: A, D, E Intervention choices A, D, and E help prevent hip dislocation or subluxation in patients who have an anterior surgical approach for a total hip arthroplasty. Avoiding flexion is necessary for

The nurse is caring for a patient treated with alteplase following a stroke. What assessment finding is the highest priority for the nurse? a. Client's blood pressure is 144/90. b. Client is having epistaxis. c. Client ate only half of the last meal. d. Client continues to be drowsy.

ANS: B Alteplase can cause bleeding and therefore the nurse assesses for indications of bleeding. Epistaxis is a nosebleed and therefore choice B is the correct answer. The client BP of 144/90 is acceptable for a stroke patient (A). The other assessments are important to document but not related to the administration of alteplase; they are also not potentially life-threatening (C and D).

The nurse is caring for a client with a bleeding duodenal ulcer who was admitted to the hospital after vomiting bright, red blood. Which condition does the nurse anticipate when the client develops a sudden, sharp pain in the midepigastric region and a rigid, board-like abdomen? a. Pancreatitis b. Ulcer perforation c. Small bowel obstruction d. Development of additional ulcers

ANS: B The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in board-like abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. A small bowel obstruction would not cause midepigastric pain. The development of additional ulcers or pancreatitis would not cause a rigid, board-like abdomen.

A client returns from the postanesthesia care unit (PACU) after a surgical removal of a brainstem tumor. What position will the nurse place the client in at this time? a. Turn the patient from side to side to prevent aspiration. b. Keep the client flat in bed or up 10 degrees and reposition from side to side. c. Elevate the head of the bed to at least 30 degrees at all times. d. Keep the client in a sitting position in bed at all times.

ANS: B The brainstem is located below the tentorium (infratentorial) and therefore the best practice position is side-lying and either flat or up 10 degrees (B). Choices C and D are not appropriate for this type of brain tumor surgery. Turning the patient side-to-side is appropriate for all types of surgery to prevent pneumonia and pressure injuries, not to prevent aspiration (A).

A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse's best initial action? a. Remove the splint to reduce skin pressure. b. Perform a neurovascular assessment. c. Report the client's concern to the primary health care provider. d. Inspect the skin under the elastic bandage.

ANS: B The first action of the nurse is to check for perfusion compromise by performing a circulation check, or neurovascular assessment. If there is no impairment, the patient may be developing a pressure area under the splint because it may be too tight. The skin cannot be inspected under the elastic bandage (D) because its purpose is to hold the splint in place. The only way to inspect the skin is to remove the splint to inspect it. That action requires direction from the primary health care provider

A client has a synthetic cast placed for a right wrist fracture in the emergency room. What priority health teaching is important for the nurse to provide for this client before returning home? (Select all that apply.) a. "Keep your right arm below the level of your heart as often as possible." b. "Use an ice pack for the first 24 hours to decrease tissue swelling." c. "Move the fingers of the right hand frequently to promote blood flow." d. "Report coolness or discoloration of your right hand to your doctor." e. "Don't place any device under the case to scratch the skin if it itches."

ANS: B, C, D, E Rest, ice, and elevation are strategies that help to prevent edema from becoming severe and causing impaired perfusion. Therefore, the arm should be above, not below the level of the heart (A). Using a pen, hanger, or other device to scratch the skin under the cast is discouraged because these devices can cause tissue damage which can worsen under the cast.

A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? a. "The pain will go away after the swelling decreases." b. "That's phantom limb pain and every amputee has that." c. "Your foot has been amputated, so it's in your head." d. "On a scale of 0 to 10, how would you rate your pain?"

ANS: D As stated in Chapter 4 of this text, pain is what the patient says it is. The nurse should acknowledge that the pain is real to the patient and perform an assessment of the pain first. All pain must be managed to prevent long-term chronic pain.

The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects?(Selectall) A.Alopecia B.Headaches C.Dizziness D.Diplopia E.Increased blood glucose

B, C, D Adverse effects the nurse must monitor for in a client taking carbamazepine for partial seizures after encephalitis include: headaches, dizziness, and diplopia. Carbamazepine affects the central nervous system, although it's mechanism of action is unclear.Carbamazepine does not cause alopecia and does not increase blood glucose. Divalproex (Depakote) and valproic acid (Depakene) may cause alopecia.

A client has Guillain-Barré syndrome. Which interdisciplinary health care team members does the nurse plan to collaborate with to help prevent pressure ulcers related to immobility in this client? (Select all ) A. Certified hospital chaplain B. Family Members C. Dietitian D. Occupational Therapist, social worker E.

B, C, D The nurse plans to collaborate with family members, the dietician, and OT to help prevent pressure ulcers in the client with GBS. Family members would help to develop interventions to prevent these ulcers, because the family will mostly likely be directly involved in the client's care. Malnutrition puts the client at greater risk for pressure ulcers, so the dietitian must be included as well. The OT can provide assistive devices that will help prevent ulcers.The certified hospital chaplain and the social worker can assist with providing additional psychosocial support but would not be involved with direct prevention of ulcers. The social worker would also assist with the discharge plan and reintegration into the community.

In preparing to care for the patient, which conditions does the nurse recognize as potential complications of acute pancreatitis? (Select all that apply.) A. Strep throat B. Pleural effusion C. Diabetes mellitus D. Pancreatic infection E. Acute kidney failure

B, C, D, E All, with the exception of strep throat are potential complications of acute pancreatitis.

During the evening shift, the nurse notes that the patient is having difficulty mobilizing secretions. Which interventions should be implemented for this problem? (Select all that apply.) A. Plasmapheresis B. Chest physiotherapy C. Coughing and deep breathing D. Oxygen at 2 L per nasal cannula E. Oropharyngeal suctioning as needed

B, C, E As muscle weakness increases, the patient is at increased risk of respiratory compromise, and aspiration. suctioning coughing and chest physiotherapy can help mobilize secretions. If the patient needs oxygen the SaO2 and PaO2 should be assessed 1st. Plasmapheresis is a method of removing antibodies from the plasma.

An hour later after a CT scan, the patient is diagnosed with a left hemisphere stroke. Which manifestations would the nurse expect? (Select all that apply.) A. Constant smiling B. Intellectual impairment C. Deficits in the right visual field D. Disorientation to time, place, and person E. Inability to discriminate words and letters

B, C, E. -Left hemisphere stroke display an inability to discriminate words and letters, intellectual impairment, deficits in the visual field. -Disorientation, smiling, and neglect of left visual field are symptoms of a right hemisphere stroke.

A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? (Select All) A. Bite block at the bedside B. Intravenous Access (IV) C. Continuous Sedation D. Suction equipment at the bedside E. Siderails raised

B, D, E Seizure precautions the nurse institutes for an admitted client with new-onset status epilepticus include IV access, suctioning equipment at the bedside and raised siderails. IV access is needed to administer medications. Suctioning equipment must be available to suction secretions and facilitate an open airway during a seizure. Raised, padded siderails may be used to protect the client from falling out of bed during a seizure.Bite blocks or padded tongue blades would not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? A. "A callus is quickly deposited and transformed into bone." B. "A hematoma forms at the site of the fracture." C. "Cellular and vascular proliferation surround the fracture site." D. "Granulation tissue reabsorbs the hematoma and deposits new bone."

B. "A hematoma forms at the site of the fracture." With a stage 1 fracture, a hematoma forms at the site of the fracture within 24 to 72 hours, because bone is extremely vascular. This action helps prompt the formation of fibrocartilage, providing the foundation for bone healing.Stage 2 of bone healing occurs within 3 days to 2 weeks after the fracture, when granulation tissue begins to invade the hematoma. Stage 3 of bone healing occurs as a result of vascular and cellular proliferation. In stage 4 of a healing fracture, callus is gradually reabsorbed and transformed into bone.

The nurse is teaching a client, newly diagnosed with migraines, about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A. "I can still eat Chinese food." B. "I must not miss meals." C. "It is okay to drink a few wine coolers." D. "I need to use fake sugar in my coffee."

B. "I must not miss meals." The client understands the teaching plan about trigger control for migraines when the client states that he/she must not miss meals. Until triggers are identified, a headache diary would be considered. Missing meals is a trigger for many people suffering from migraines. The client must not skip any meals until the triggers are identified.Chinese food frequently contains monosodium glutamate. Monosodium glutamate-containing foods, alcohol, and artificial sweeteners are triggers for many people suffering from migraines and need to be eliminated until the triggers are identified.

The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? A. "I do not know how long my wife will be able to take care of me at home." B. "The bus is coming to pick me up from the senior center three times a week so I can play cards." C. "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." D. "I do not know how much longer my neighbor can continue to help clean my house."

B. "The bus is coming to pick me up from the senior center three times a week so I can play cards." Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support.

Which client is at greatest risk for slow wound healing? A. A 12-year-old healthy girl B. A 47-year-old obese man with diabetes C. A 48-year-old woman who smokes D. A 98-year-old healthy man

B. A 47-year-old obese man with diabetes Obesity and diabetes would significantly put a client at greatest risk for slow wound healing.The healthy 12-year-old would likely heal quickly. The 48-year-old smoker will experience delayed wound healing, but is not as high a risk as an obese client who is diabetic. The healthy 98-year-old is not at risk for delayed wound healing.

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction prior to surgical repair? A. Balanced skin traction B. Buck's traction C. overhead traction D. plaster traction

B. Buck's traction Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm.Balanced skin traction is indicated for fracture of the femur or pelvis. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. Plaster traction is indicated for wrist fracture.

As the nurse obtains informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? A. Contact the anesthesiologist B. Contact the surgeon C. Explain the procedure. D. Have the client sign the form.

B. Contact the surgeon. The nurse will contact the surgeon to convey the client's question. The nurse is not responsible for explaining or providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience.The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed.

Which action does the nurse implement for a client with wound evisceration? A. Apply direct pressure to the wound. B. Cover the wound with a sterile, warm, moist dressing. C. Irrigate the wound with warm, sterile saline. D. Replace tissue protruding into the opening.

B. Cover the wound with a sterile, warm, moist dressing. Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Evisceration occurs when a wound opens up and body organs are exposed.Applying direct pressure to a wound traumatizes the organs. Irrigating the wound is not necessary. Replacing protruding tissue could induce infection.

A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? A. Decreased sensation in the lower extremities B. Diminished peripheral pulses in the lower extremities C. Pale, cool extremities D. Reddened areas over bony prominences

B. Diminished peripheral pulses in the lower extremities The nurse is most concerned with diminished peripheral pulses in the lower extremities. This could indicate diminished blood flow.Decreased sensation; pale, cool extremities; and reddened areas over bony prominences can be normal occurrences in clients who have undergone a long surgical procedure.

The nurse is ordered to administer Lorazepam to a patient experiencing status epilepticus. As a precautionary measure, the nurse will also have what reversal agent on standby? A.Narcan B.Flumazenil C.Calcium Chloride D.Idarucizumab

B. Flumazenil Reversal agent for lorazepam.

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? A. Check for fecal impaction B. Help the client sit up. C.insert a straight catheter D. loosen the clients clothing.

B. Help the client sit up. The nurse's first action for a T6 spinal cord injury client suddenly developing facial flushing and severe headache is to help the client sit up. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain.Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important but will not immediately reduce blood pressure.

What priority laboratory analysis should the nurse review when caring for a patient with Crohn's disease? A. Potassium B. Hemoglobin C. Serum albumin D. C-reactive protein

B. Hemoglobin Crohn's disease presents as transmural inflammation that causes a thickened bowel wall, strictures, and deep ulceration's that result in severe diarrhea and malabsorption or vital nutrients.

What symptom does the nurse expect the patient with intussusception to exhibit? A. Decrease in pulse B. Singultus (hiccups) C. Frequent bloody stools D. Extremely elevated body temperature

B. Hiccups Intussusception is a telescoping of the intestine within itself. Hiccups is common will all types of intestinal obstruction. The vagus nerve stimulate the hiccup reflex. obstruction can increase the intraabdominal pressure causing pressure on the phrenic nerve and the symptom of singultus.

A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? A. Aphasia and cautiousness B. Impulsiveness and smiling C. inability to discriminate words D. quick to anger and frustration

B. Impulsiveness and smiling Impulsiveness and smiling are signs and symptoms indicative of a right hemisphere stroke.Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration are signs and symptoms indicative of a left hemisphere stroke.

Which element is a risk factor for osteoarthritis (OA)? A. Thin build B. Obesity C.Nonsmoker D. Male

B. Obesity Having a thin build does not place an individual at higher risk for slow joint degeneration and the development of OA. Smoking leads to knee cartilage loss, especially in clients with a family history of knee OA. Women tend to develop OA more than men, and it is believed that obesity may be a contributing factor; as women age and have children, they tend to gain more weight than men.

A 68-year-old patient presents to the ED the day after Thanksgiving, stating that he has "eaten and drunk quite a bit." He states that about 1 hour ago he experienced a sudden onset of pain in the left upper quadrant that radiates to his left flank. He rates the pain as an 8 on a 0-to-10 scale. The patient is admitted with acute pancreatitis. Which laboratory finding corroborates the diagnosis of acute pancreatitis? A. Serum lipase, 150 U/L B. Serum amylase, 200 U/L C. Serum glucose, 80 mg/dL D. White blood cells (WBCs), 6000 mcL

B. Serum amylase, 200 U/L serum amylase is elevated (normal 23-85). lipase normal 0-160. WBC 4800-10,800. glucose is often higher than normal with acute pancreatitis.

The patient is a 21-year-old who has recently been diagnosed with ulcerative colitis (UC). In the ED, she tells the nurse that she has been having 7 to 8 bloody stools daily. Upon assessment, the nurse finds that her heart rate is 120/min, and she has abdominal pain upon palpation. Laboratory results show a hemoglobin level of 9 g/dL. How is the severity of the patient's ulcerative colitis categorized? A. Mild B. Severe C. Moderate D. Fulminant

B. Severe UC presents with greater than 6 bloody stools daily, and may include fever, achy cardia, anemia, abdominal pain, and elevated C-reactive protein, and or ESR.

Following x-rays of an injured wrist, the patient is informed that it is badly sprained after a fall from a soccer game 3 days ago. In teaching the patient to care for the injury, the nurse tells the patient to... a.) apply a heating pad to reduce muscle spasms. b.) wear an elastic compression bandage continuously. c.) use pillows to keep the arm elevated above the heart. d.) gently exercise the joint to prevent muscle shortening.

C) use pillows to keep the arm elevated above the heart. Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist should be rested and kept immobile to prevent further swelling or injury.

A client is considering treatments for a malignant brain tumor. Which statement by the client indicates a need for further instruction by the nurse? A. "A combination of treatments might be necessary." B. "In a craniotomy, holes are cut in the skull to access the tumor." C. "I can go home the day of my craniotomy." D. "The goal is to decrease tumor size and improve survival time."

C. "I can go home the day of my craniotomy." The nurse knows that further instruction is needed when a client considering treatment for malignant brain tumor says, "I can go home the day of my craniotomy." Craniotomies are inclient procedures. The client will be admitted to critical care for monitoring after the procedure and may be mechanically ventilated for 24-48 hours postprocedure.Chemotherapy, radiation, and surgery are often used in conjunction with each other to treat malignancies. For a craniotomy, several burr holes are drilled into the skull, and a saw is used to remove a piece of bone (bone flap) to expose the tumor area. The goals of treatment of brain tumor are to decrease tumor size, improve quality of life, and improve survival time.

The nurse is caring for a patient with peptic ulcer disease (PUD). Which patient statement requires nursing teaching? A. "When I eat out, I avoid spicy foods." B. "I sit up for at least an hour after I eat my meals." C. "My doctor said to take ibuprofen for my aches and pain." D. "After I quit work, my stress level decreased substantially."

C. "My doctor said to take ibuprofen for my aches and pain." NSAID use can aggravate symptoms associates with PUD, provide teaching about this factor.

The daughter of a client who has had a stroke asks the nurse for additional resources. What is the nurse's best response? A. "Call hospice" B. "Check the internet" C. "The National Stroke Association has resources available." D. "The charge nurse at the desk has all of the information."

C. "The National Stroke Association has resources available." The nurse's best response about additional resources for stroke is the National Stroke Association. The National Stroke Association is a specific and reliable resource that can be recommended. Additional resources are frequently provided as part of the discharge teaching the nurse will provide.Hospice care is appropriate for clients who are terminally ill, not a client who has had a stroke necessarily. Sources on the Internet may be very broad and unreliable or lack evidence to support their recommendations. The role of the client's nurse is to advocate for the client and not to refer all questions to the charge nurse.

A client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label? A. "Are you Mr. Smith?" B. "Good morning, Mr. Smith." C. "What is your name, and when were you born?" D. "What surgery are you having today?"

C. "What is your name, and when were you born?" The nurse must verify the client's identity with two types of identifiers, such as name and birthdate. This practice prevents errors by drowsy or confused clients.When asked to verify his or her name, or respond to a greeting, the client may respond inappropriately if he or she is anxious or sedated. Asking the client about his or her surgery does help with identification. However, it is really done to ascertain that the client's perception of the procedure, the operative permit, and the operative schedule are the same.

The nurse is caring for a patient with crush injuries to the lower extremities. For which complication will the nurse monitor? A. Bradycardia B. Hypotension C. Acute kidney injury D. Spinal nerve injury

C. Acute Kidney Injury Crush injuries release myoglobin from the muscle places the patient at risk for rhabdomyolysis and acute kidney injury.

The nurse understands which symptom is the earliest indicator of increased intracranial pressure when caring for a patient with a head injury? A.Increased pupil size B.Nausea and vomiting C.Agitation and confusion D.Elevated blood pressure

C. Agitation and confusion. First sign of increased ICP is declining or changing level of consciousness. Patients may be agitated or slightly confused before progressing to difficult to arouse as an early assessment variable of increased ICP. Changes in vital signs, nausea, vomiting, and pupillary response occur as ICP increases.

An alert client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver? A. Use an abduction pillow between the legs. B. Keep heels off the bed. C. Avoid using a straight razor. D. Re-orient frequently.

C. Avoid using a straight razor. Using a straight razor should be avoided. The client will be on anticoagulants for 4 to 6 weeks at home and should avoid injury to the skin that can occur when shaving.

A client is in skeletal traction. Which nursing intervention ensures proper care of this client? A. Ensure that weights are placed on the floor. B. Ensure that pins are not loose and tighten as needed. C. Inspect the skin at least every 8 hours. D. Remove the traction weights only for bathing.

C. Inspect the skin at least every 8 hours. The client's skin should be inspected at least every 8 hours for signs of irritation, inflammation, or actual skin breakdown.Weights must never rest on the floor because they will not be effective. They must hang freely at all times. Pin sites would be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Traction weights are not removed for bathing.

When positioning to promote comfort in the postoperative patient, which intervention is most appropriate? A. Raise the knee gatch of the bed. B. Place pillows under the patient's knees. C. Reposition the patient at least every 2 hours. D. Allow the patient to get out of bed as soon as possible.

C. Reposition the patient at least every 2 hours. Raising the knee could restrict circulation. During PACU the patient most likely won't be able to get out of bed.

How does the nurse position a client with postoperative nausea and vomiting? A. Flat in bed, with the head in alignment with the body B. Prone, with the head of the bed flat C. Side-lying, with the head in a neutral position D. Supine in bed, with the neck flexed

C. Side-lying, with the head in a neutral position The side-lying position with the client's head in a neutral position helps reduce postoperative nausea and vomiting.The flat-in-bed position with the head in alignment is not a neutral position. The prone position with the head of the bed flat is unnatural, as is the supine position with the neck flexed.

The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? A. Neck pain is at a level 7 on a 0-to-10 scale. B. Serosanguineous fluid oozes onto the neck dressing. C. The client is reporting difficulty swallowing secretions. D. The client has numbness and tingling bilaterally down the arms.

C. The client is reporting difficulty swallowing secretions. The nursing assessment finding that is the greatest concern for a postoperative anterior cervical diskectomy client is the client reporting difficulty swallowing secretions. This may indicate swelling in the neck and the potential for compromise of the client's airway.Experiencing neck pain and numbness and tingling bilaterally down the arms are expected findings after this surgery. Serosanguineous fluid oozing onto the neck dressing is also a normal finding after this surgery.

A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? A. Embolic stroke B. Hemorrhagic stroke C. Thrombotic stroke D. Transient ischemic attack

C. Thrombotic stroke The client's signs and symptoms fit the description of a thrombotic stroke due to its gradual onset.Signs and symptoms of embolic stroke have a sudden onset, unlike this client's symptoms. Hemorrhagic strokes more frequently present with sudden, severe headache. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.

A patient in the ED has been experiencing upper abdominal pain after meals for the past several months. She reports pain after napping or sleeping at night. She has been taking OTC antacids with some relief. The nurse understands that which assessment finding places the patient at risk for peptic ulcer disease? A. GERD 4 years ago B. Weight loss of 35 lbs C. Use of NSAIDs to control arthritis pain D. Recent discontinuation of prednisone (Deltasone)

C. Use of NSAIDs to control arthritis pain Peptic ulcer development is associated primarily with NSAID use and bacterial infections with helicobacter pylori.

The patient is preparing for discharge. She asks what is the best way to keep her skin from breaking down. What is the appropriate teaching the nurse will provide? A."Add high-fiber or high-cellulose foods to your diet." B."Apply a pectin-based skin barrier after each bowel movement." C."Wash with mild soap and warm water after each bowel movement." D."Take a laxative daily at bedtime to facilitate morning bowel movements."

C."Wash with mild soap and warm water after each bowel movement." good skin care after each bowel movement is the best way to protect from excoriation or irritation

What is the nursing priority in the management of a patient with a newly active upper GI bleed? A.Obtain vital signs. B.Notify the physician. C.Apply oxygen by nasal cannula. D.Type and cross match the patient for blood products.

C.Apply oxygen by nasal cannula. Oxygen will assist with delivery of oxygen to the tissues, vital signs are then needed to evaluate the severity of the patients bleed and hypovolemic status, which can then be reported ti the DR. a type and cross match although important can take place later.

The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of the Joint Commission National Patient Safety Goals (NPSG), what will the nurse be required to do? A. Ensure that the correct procedure is noted in the client's history. B. Remind the surgeon that the client will have a left knee arthroscopy. C. Verify with the client that a left knee arthroscopy will be performed. D. Mark the left knee site with the client awake and the surgeon present.

D Mark the left knee site with the client awake and the surgeon present. The nurse will be required to mark the left knee site with the client awake and the surgeon present. The Joint Commission NSPG requires that the surgical site be marked by an independent licensed professional and should, when possible, involve the client. The surgeon is accountable and should be present.The EMR should identify the correct procedure, but is not a specific JCAHO requirement. The nurse will verify the procedure with the client when possible, but this is not a requirement. Communication with the surgeon is ideal, but is not specifically required.

The nurse has given instructions to a client returning home after knee arthroscopy from a meniscus tear. Which statement by the client indicates that the instructions are understood? A)" I can resume regular exercise tomorrow." B) "I can't eat food for the remainder of the day." C) "I need to stay off the leg entirely for the rest of the day". D) "I need to report a fever or swelling to my healthcare provider".

D) "I need to report a fever or swelling to my healthcare provider". After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the health care provider (HCP).

The nurse is caring for a postoperative client with total joint arthroplasty. What actions does the nurse take to prevent venous thromboembolism (VTE) postoperatively? (Select all that apply) A. Massage the legs B. Keep the legs slightly abducted C. Use the knee catch on the bed. D. Apply elastic Stockings E. Administer anticoagulants

D, E Correct Feedback: Support stockings provide compression, which helps prevent VTE. Anticoagulants also help prevent VTE because they inhibit the formation of blood clots. Incorrect Feedback: The legs should never be massaged, because it could cause a blood clot to dislodge. Legs are kept slightly abducted to prevent adduction. Using the knee gatch can constrict circulation in the popliteal area and should be avoided.

When counseling an older patient about ways to prevent fractures, which information will the nurse include? A. Tacking down scatter rugs in the home is recommended. B. Occasional weight-bearing exercise will improve muscle and bone strength. C. Most falls happen outside the home. D. Buying shoes that provide good support and are comfortable to wear is recommended.

D. Good shoes with good support will help to decrease the risk for falls, scatter rugs should be eliminated not just tacked down, regular exercise will improve strength but occasional exercise is not helpful in improving strength.

A client with a fracture asks the nurse about the difference between an open fracture and a simple fracture. Which statement by the nurse is correct? A. "Simple fracture involves a break in the bone, with skin contusions." B. "An open fracture does not extend through the skin." C. "Simple fracture has an increased risk for infection and emboli." D. "An open fracture involves a break in the bone, with damage to the skin."

D. "An open fracture involves a break in the bone, with damage to the skin." The correct statement made by the nurse states that an open fracture involves a break in the bone with damage to the skin.A simple fracture does not extend through the skin. An open fracture, not a simple fracture, has an increased risk for infection.

The nurse is teaching a client about the difference between rheumatoid arthritis (RA) and osteoarthritis (OA). Which statement by the client indicates a need for further teaching? A. "RA is inflammatory. OA is degenerative." B. "The risk factors or causes of RA are probably autoimmune, whereas OA may be caused by age, obesity, trauma, or occupation." C. "The typical onset of RA is seen between 35 and 45 years of age, whereas the typical onset of OA is seen in clients older than 60 years." D. "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints."

D. "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints." Further teaching is needed if the client states that, "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints." OA is unilateral and usually affects a single joint, whereas RA is bilateral and affects multiple joints.

A 40-year-old patient has a tight cast on the left lower leg. Which assessment finding would prompt the nurse to assess further for early signs of compartment syndrome? A. Numbness of the toes B. Paralysis of the left leg C. Diminished pulse in the left lower extremity D. Pain more intense than expected based on initial injury

D. 1st sign of compartment syndrome is pain. Paralysis, numbness, and diminished pulse are late signs of compartment syndrome.

As the unit nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do after verifying the procedure with the client? A. Calls the surgeon B. Calls the anesthesiologist C. Gives the medication as ordered D. Asks the client to sign the consent form

D. Asks the client to sign the consent form The unit nurse will ask the client to sign the consent form, after which the medication can be administered.Calling the surgeon or the anesthesiologist is not necessary. It is illegal for the client to sign the permit after being sedated.

A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? A. Use electric clippers to cut hair at the surgical site. B. Start an infusion of lactated Ringer's solution at 75 mL/hr. C. Administer one-half of the client's usual lispro insulin dose. D. Draw blood for glucose, electrolyte, and complete blood count values.

D. Draw blood for glucose, electrolyte, and complete blood count values. The blood sample needs to be drawn and sent to the laboratory first to confirm that results are within normal limits. If blood work is abnormal, the surgery may be rescheduled.Removal of hair can be accomplished in the operating room directly before the start of surgery. The IV infusion can be accomplished after the laboratory orders have been completed. The nurse should check blood glucose with the laboratory orders before administration of lispro.

The nurse is caring for a patient who sustained a knee injury at work. The nurse explains that which diagnostic test best demonstrates soft tissue damage in the area of the injury? A. Knee x-ray B. Electromyography (EMG) C. Computed tomography (CT) D. Magnetic resonance imaging (MRI)

D. MRI for soft tissue damage. x-rays and CT are helpful in determining simple and complex bone fractures. EMG is for muscle problems.

Colostomy surgery is categorized as what type of surgery? A. Cosmetic B. Curative C. Diagnostic D. Pallative

D. Palliative Colostomy surgery is categorized as palliative. Palliative surgery is performed to relieve symptoms of a disease process, but does not cure the disease.Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer.

A patient with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first? A. Administers medication for pain B. Changes the nasogastric suction level from "intermittent" to "constant" C. Positions the patient in high-Fowler's position D. Prepares the patient for emergency surgery

D. Prepares the patient for emergency surgery The first action the nurse takes for a patient with intestinal obstruction whose pain changes from "colicky" intermittent type to constant discomfort is to prepare the patient for emergency surgery. The change in pain type could be indicative of perforation or peritonitis and will require immediate surgical intervention.Pain medication may mask the patient's symptoms but will not address the root cause. A change in the nasogastric suction rate will not resolve the cause of the patient's pain and could be particularly ineffective if a nonvented tube is in use. A high-Fowler's position will have no effect on an intestinal perforation or peritonitis, which this patient is likely experiencing.

A patient received one positive fecal occult blood test. Which response is most appropriate? A. The patient has colon cancer B. The patient has bleeding in the GI tract C. The patient may be taking Aspirin D. The patient will need two samples on three consecutive days.

D. The patient will need two samples on three consecutive days. 2-3 occult blood tests on 3 consecutive days are needed fully to assess for blood in the stool. A positive result may mean that the patient has cancer, or bleeding or has been taking medication, one test could be a false positive. Obtain additional samples for testing.

Which patient statement would cause the nurse to suspect that she may have Zollinger-Ellison syndrome (ZES)? A. "I can't lie flat for awhile after I've eaten." B. "I feel much better after taking Zantac (ranitidine)." C. "Occasionally I have pain in my left lower quadrant." D. "The stomach pain hurts, but the foul-smelling diarrhea is worse."

D. The stomach pain hurts, but the foul smelling diarrhea is worse. Symptoms of ZES are similar to those of peptic ulcer disease. diarrhea occurs in almost half the patients, which may be associated with large amounts of hydrochloric acid secreted into the proximal duodenum.

The nurse is developing a teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? A. Begin a running program B. Take up knitting to slow down joint degeneration C. Eat at least 2 cups (17 ounces) of yogurt per day. D. Wear supportive shoes.

D. Wear supportive shoes. Wearing supportive shoes will help prevent falls and damage to foot joints, especially metatarsal joints.

The patient tells the nurse that he was jogging to train for a marathon, which has been a lifelong goal. He asks, "Will I ever be able to run a marathon now?" What is the appropriate nursing response? A. "The doctor will be able to tell you that." B. "Of course, after this heals, you will be fine." C. "It is unlikely that your ankle will regain the necessary strength." D. "It sounds like you are concerned that you may not be able to achieve your goal."

D. acknowledging the patent's goal recognizes his feelings and allows him to express his concerns.

A patient has recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor the patient's laboratory results for evidence of which condition? A.Hyperkalemia B.Hypernatremia C.Hypercalcemia D.Hyperglycemia

D.Hyperglycemia Long term adverse effects that commonly occur with steroid therapy include hyperglycemia, osteoporosis, peptic ulcer disease and increased risk for infection.

The patient states, "I am afraid I'll never get to go out with my friends again because I can't be away from the toilet." Which is the appropriate nursing response? A."What makes you say that?" B."Your friends will understand." C."I wouldn't worry about it if I were you." D.It sounds like you are concerned about managing this disorder when you are out."

D.It sounds like you are concerned about managing this disorder when you are out." implied concern.

If patient is allergic to avocado, bananas, and strawberries what would you suspect they are also allergic to?

Latex Allergy

In the care of a patient with acute pancreatitis, which assessment parameter requires immediate nursing intervention? A.Heart rate of 105 beats/min B.Serum glucose of 136 mg/dL C.Blood pressure of 102/76 mm Hg d.Respiratory rate of 28 breaths/min

d.Respiratory rate of 28 breaths/min PT with pancreatitis may develop pulmonary complications pleural effusions pulmonary infiltrates and acute respiratory failure or ARDS.

A patient has experienced a stroke in the left cerebral hemisphere. What clinical presentation does the nurse expect? (Select all that apply.) A. Aphasia B. Decreased proprioception C. Disoriented to time and place D. Agraphia E. Difficulty with math calculation

A, D, E The RIGHT cerebral hemisphere is more involved with visual and spatial awareness. A person who has a stroke involving the right cerebral hemisphere is often unaware of any deficits and may be disoriented to time and place. personality changes involve impulsivity and poor judgement. LEFT hemisphere is dominate in all but about 15%-20% of the population. It is the center for language, math skills, analytic thinking. LEFT stroke may result in Aphasia, Alexia, Agrphia, Acalculia.

A client's spouse expresses concern that the client, who has Guillain-Barré syndrome (GBS), is becoming very depressed and will not leave the house. What is the nurse's best response? A. "Contact the Guillain-Barré Syndrome Foundation International for resources. Here is their contact information." B. "Try inviting several people over so the client won't have to go out." C. "Let your spouse stay alone. Your spouse will get used to it." D. "This behavior is normal."

A. "Contact the Guillain-Barré Syndrome Foundation International for resources. Here is their contact information." The nurse's best response to a client's spouse about the client with GBS being depressed is referring the client to the GBS Foundation for resources. The Guillain-Barré Syndrome Foundation International (www.gbs-cidp.org) provides resources and information for clients and their families. The Foundation may be able to help the spouse and family find local support groups to assist the family with the transition.Inviting one close friend over is appropriate, but more than one might overwhelm the client. Telling the spouse to let the client say alone and that the behavior is normal is not helpful and inappropriate. Although depression is expected initially, some action does need to be taken to prevent further deterioration.

A client newly diagnosed with Parkinson disease (PD) is being discharged. Which instruction is best for the nurse to provide to the client's spouse? A. Administer medications promptly on schedule to maintain therapeutic drug levels. B. Complete activities of daily living for the client. C. Provide high-fiber, high-carbohydrate foods. D. Speak loudly for better understanding.

A. Administer medications promptly on schedule to maintain therapeutic drug levels. Administering medications promptly on schedule is a correct statement.The best instruction the nurse can give to the spouse of a PD client about to be discharged is to give schedule medications promptly in order to keep drug levels therapeutic.

A 19-year-old man who was involved in a motor vehicle accident is brought to the ED. The patient was stopped at a red light when he was hit from behind by another vehicle traveling at 15 mph. The patient was placed in a cervical immobilizer by the paramedics. He is alert and oriented, states that his neck hurts, and is in no apparent distress. He currently rates his neck pain as a "5" on a 0-to-10 scale. Which assessment will the nurse perform first? A. Airway B. Circulation C. Sensory-motor D. Level of consciousness

A. Airway Even if no apparent distress the airway must always be assessed first.

A nursing student is assessing a student upon entry to the surgical suite. Which statement by the nurse would cause the nurse to intervene? A. "Are you Mr. Green?" B. "What kind of operation are you having today?" C. "Do you have any allergies?" D. "Have you donated blood for this surgery?"

A. Are you Mr. Green? -Join commission's national patient safety goals states correct identification of the patient is the responsibility of every member of the health care team. You should ask the patient to state their name and birthdate. Reduces errors by confused patients.

The wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress? A. Arranges for respite care B. Provides positive reinforcement and support to the wife C. Restrains the client for a short time each day, to allow the wife to rest D. Teaches the client improved self-care

A. Arranges for respite care The home health nurse can help relieve caregiver stress for the wife caring for her husband with Alzheimer's disease by arranging for respite care for the wife. Respite care can give the wife some time to reenergize and will provide a social outlet for the client.Providing positive reinforcement and support is important but does not help provide a solution to the wife's situation. Restraints are almost never appropriate and are used only as a last resort. The client with Alzheimer's disease typically is unable to learn improved self-care.

A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? A. Assesses airway, breathing, and circulation B. Calls the provider C. Performs a neurologic check D. Assists the client to a sitting position

A. Assesses airway, breathing, and circulation When a client reports "feeling funny" and then starts slurring words and has right-sided weakness, the nurse must first assess for airway, breathing, and circulation. The priority is assessment of the "ABCs"—airway, breathing, and circulation.Calling the Rapid Response Team, not the provider, after assessing ABCs would be appropriate. The first 10 minutes after onset of symptoms is crucial. A neurologic check will be performed rapidly but is not the top priority. The client would be placed in bed, easily accessible for healthcare providers to assess and begin treatment. This does not need to be a seated position.

A client with a traumatic brain injury from a motor vehicle crash is monitored for signs/symptoms of increased intracranial pressure (ICP). Which sign/symptoms does the nurse monitor for? A. Changes in breathing pattern. B. Dizziness C. increasing level of consciousness D. reactive pupils

A. Changes in breathing pattern The nurse monitors for changes in breathing pattern. This may be indicative of increased intracranial pressure secondary to compression of areas of the brain responsible for respiratory control.Dizziness is a symptom of brain injury, not increased intracranial pressure. Increasing level of consciousness and reactive pupils are desired outcomes for this client.

A client will be receiving plasmapheresis for treatment of Guillain-Barre'syndrome (GBS). Which posttreatment test will the nurse anticipate to be ordered? A. Electrolyte panel B. Electroencephalogram (EEG) C. Lumbar puncture D. Urinalysis

A. Electrolyte panel For the client receiving plasmapheresis for treatment of GBS, the nurse expects that an electrolyte panel will be ordered. Electrolytes will be checked since citrate-induced hypocalcemia is a complication of plasmapheresis.An electroencephalogram evaluates brain waves and is useful in detecting seizure activity. It would not be beneficial in this situation. A lumbar puncture might have been performed as part of the diagnostic process initially but not as part of posttreatment. There is no role for a urinalysis after plasmapheresis.

Following surgery, a patient is wearing pneumatic compression devices. The patient asks, "Why do I have to wear these?" What is the most appropriate nursing response? A. "This helps to prevent blood clots." B. "It will make your legs feel more comfortable." C. "This prevents skin breakdown from immobility." D. "It will make it easier on you when you start to ambulate."

A. Helps prevent blood clots. VTE prophylaxis may involve devices and drug therapy. Devices may be used during and after surgery along with leg exercises and ambulation to promote venous return.

The next morning, the nurse notes that the patient's heart rate is 48/min and blood pressure is 78/66. His skin is warm and dry. What is the nurse's best first action? A. Notify the provider immediately. B. Raise the head of the bed to 45 degrees. C. Apply oxygen at 2 L per nasal cannula. D. Increase the IV rate from 50 to 75 mL/hr.

A. Notify provider immediately. Manifestations of neurogenic shock include severe bradycardia, warm and dry skin, severe hypotension. The DR should be notified because that is an emergency. Best treated by restoring fluids to the circulating blood volume. Increasing the IV rate is a good intervention but 50 to 75ml will not be enough and requires a physicians order.

A patient has had bowel surgery. Which symptom, assessed by the nurse, is the best indicator of intestinal activity? A. Passage of flatus or stool B. Patient's report of hunger C. Abdominal cramping with distention D. Detection of bowel sounds upon auscultation

A. Passage of flatus or stool. -The presence of active bowel sounds usually indicates return of peristalsis. Abdominal cramping along with distention shows nonmoving gas, not peristalsis.

During morning care, the patient is able to brush her teeth, wash her face, and brush her hair. She becomes fatigued after performing these actions. What is the appropriate nursing action? A. Provide assistance in completing the patient's morning care. B. Let her rest for 15 minutes and then continue self morning care. C. Document that the patient refuses morning care because of fatigue. D. Encourage her to continue with her own morning care to increase her strength.

A. Provide assistance in completing morning care. MG creates muscle weakness, and increases when the patient is fatigued. provide assistance as necessary to prevent the patient from becoming too fatigued.

Later that day, the patient asks the nurse about activities she can do after her recovery. Which activity will the nurse discourage? A. Sunbathing B. Wearing sunglasses C. Walking in her neighborhood D. Taking medication as directed

A. Sunbathing MG patients should avoid getting overheated. Sunglasses to protect eyes, walk for exercise, and take medications as directed.

Which statement correctly illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)? A. The client's respiratory status and muscle function are affected by both diseases. B. Both diseases are autoimmune diseases with ocular symptoms. C. Both diseases exhibit exacerbations and remissions of their signs and symptoms. D. Demyelination of neurons is a cause of both diseases.

A. The client's respiratory status and muscle function are affected by both diseases. The correct statement about the commonality between GBS and MG is that both diseases affect the respiratory and muscular system. Both GBS and MG affect clients' respiratory status and muscle function.Only MG is an autoimmune disease with ocular symptoms and is characterized by exacerbations and remissions, whereas GBS has three acute stages. GBS causes demyelination of the peripheral neurons.

Which statements about stroke prevention indicate a client's understanding of health teaching by the nurse? (Select all that apply.) a. "I will take aspirin every day." b. "I have decided to stop smoking." c. "I will try to walk at least 30 minutes most days of the week." d. "I need to cut down a lot on my drinking." e. "I'm going to decrease salt in my diet."

ANS: B, C, D, E Smoking, lack of exercise, excessive drinking, and a high salt intake are all risk factors for developing a stroke. Therefore, choices B, C, D, and E are the correct answers that show that the client needs to make lifestyle changes in these areas. Daily aspirin should only be taken on the advice of a primary health care provider.

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A. Assessing neurologic status at least every 2-4 hours B. Decreasing environmental stimuli C. Managing pain through drug and nondrug methods D. Strict monitoring of hourly intake and output

A> Assessing neurologic status at least every 2-4 hours The highest priority nursing intervention for the newly admitted client with bacterial meningitis is to accurately monitor and record the client's neurologic status every 2-4 hours. The neurologic status, vital signs, and vascular status must be assessed at least every 4 hours or more often, if clinically indicated, to rapidly determine any deterioration in status.Decreasing environmental stimuli is helpful for the client with bacterial meningitis but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management which may be accomplished through both pharmacologic and nonpharmacologic methods. Assessing fluid balance while preventing overload is not the highest priority however intake and output must be monitored.

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? A. Cloudy, turbid CSF B. Decreased white blood cells C. Decreased protein D. Increased glucose

A> Cloudy, turbid CSF Cloudy, turbid CSF indicates to the nurse that the client may have bacterial meningitis.Clear fluid is a sign of viral meningitis. Increased white blood cells, increased protein, and decreased glucose are signs of bacterial meningitis.

A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? A. Assessing for Grey Turner's sign B. Maintaining neutral head position C. Placing the client in the Trendelenburg position D. Suctioning the client frequently

ANS B. Maintaining neutral head position To prevent ICP in a client with traumatic brain injury who is being mechanically ventilated, the nurse needs to maintain the patent's head in a neutral position. Maintaining the head in neutral alignments prevents obstruction of blood flow and is an important component of ICP.Grey Turner's sign is a bluish gray discoloration in the flank region caused by retroperitoneal hemorrhage. The head of the bed needs to be at 30 degrees. The Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning would be avoided because it increases ICP.

A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? A. "Next time you eat, try lifting your chin when you swallow." B. "Let's advance your diet to solid food." C. "Let's see if the dietitian can help." D. "Let's see if the speech-language pathologist can help."

ANS D. "Let's see if the speech-language pathologist can help." The nurse's best response about food gathering in the cheek of a stroke client is to see what the speech pathologist says may help. The speech-language pathologist identifies strategies to prevent food from accumulating in the cheek of the affected side of a client recovering from a stroke. The speech pathologist will assist the client with tongue exercises that will help move the food bolus to the unaffected side.Lifting the chin is not an appropriate technique. A solid diet would not necessarily be the best choice. The dietitian will be consulted to evaluate the nutritional status of the client as well as make recommendations regarding the correct diet.

The nurse is monitoring a client after supratentorial surgery. Which sign/symptom does the nurse report immediately to the provider? A. Periorbital edema B. Bilateral ecchymoses of both eyes C. Moderate amount of serosanguineous drainage on the head dressing D. Decorticate positioning

ANS D. Decorticate positioning In a postoperative supratentorial client, the nurse must immediately report decorticate positioning to the provider. The major complications of supratentorial surgery are increased intracranial pressure from cerebral edema or hydrocephalus and hemorrhage. Decorticate positioning indicates damage to the pathway between the brain and the spinal cord.Periorbital edema and a small-to-moderate amount of serosanguineous drainage are expected after a craniotomy. Ecchymoses in the facial region, especially around the eyes, are expected after a craniotomy.

A client is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the client? A. Glasgow Coma Score (GCS) B. Intracranial pressure monitor C. Mini-Mental State Examination (MMSE; mini-mental status examination) D. National Institutes of Health Stroke Scale (NIHSS)

ANS D. National Institutes of Health Stroke Scale (NIHSS) The nurse uses the NIHSS tool to perform a focused neurologic assessment. Health care providers and nurses at designated stroke centers use a specialized stroke scale such as the NIHSS to assess clients.The Glasgow Coma Score (GCS) provides a non-specific indication of level of consciousness. An intracranial pressure monitor would be requested by the health care specialist if signs and symptoms indicated increased intracranial pressure. The MMSE is used primarily to differentiate among dementia, psychosis, and affective disorders.

A client with early dementia asks the nurse to find her mother who is deceased. What is the nurse's most appropriate response? a. "We can call her in a little while if you want." b. "Your mother died over 20 years ago." c. "What did your mother look like?" d. "I'll ask your father to find her when he visits."

ANS: B The client has early dementia which means that he or she experiences times of orientation and other times where memory is decreased. Therefore, the best response is to reorient the client to reality in this case.

The nurse is preparing to administer Sinemet to a client whose most blood pressure is 88/50 while lying in bed. What is the nurse's priority action at this time? a. Instruct the client to get out of bed slowly. c. Withhold the drug until contacting the health care provider. c. Ask the client about the presence of hallucinations. d. Take the patient's apical pulse and temperature.

ANS: B The client should not get out of bed because the systolic blood pressure will likely drop and the patient may become dizzy or perhaps have syncope (A). While Sinemet can cause hallucinations, it can also cause severe hypotension. Therefore, the priority action is for the nurse to withhold the drug until contacting the primary health care provider at this time, or choice B. Taking the pulse and temperature may be performed, but are not the priority action in response to a very low blood pressure (D).

The nurse assesses an older adult with a diagnosis of severe, late-stage Alzheimer's disease. Which assessment findings would the nurse expect for this client? (Select all that apply.) a. Acute confusion b. Hallucinations c. Wandering d. Urinary incontinence e. Difficulty eating

ANS: B, D, E The client with severe, late-stage Alzheimer's disease (AD) is not able to ambulate, so C is not a correct answer. They often become psychotic, are incontinent, and cannot perform ADLs, which makes B, D, and E the correct choices for this question. Clients with AD have chronic confusion, not acute confusion, so A is also not correct.

The nurse is caring for a patient with expressive (Broca's) aphasia. Which nursing intervention is appropriate for communicating with the client? a. Refer the patient to the speech-language pathologist. b. Speak loudly to help the client interpret what is being said. c. Provide pictures to help the client communicate. d. Ask the client to read messages on a white board.

ANS: C The client with expressive aphasia has difficulty speaking and writing, and usually little problem with understanding. Therefore, it would not be useful to ask the client to read from a white board (D). Speaking loudly is not appropriate because the client has a speech problem, not a hearing problem (B). While referral to a speech-language pathologist is an appropriate intervention, it does not help to communicate with the client at this time (A). Providing pictures to the client allows him or her to communicate graphically rather than by verbalizing; therefore, C is the best answer.

The nurse is caring for a client with chronic confusion who often yells and screams when touched. Which nursing intervention is most appropriate when caring for this client? a. Provide a large clock and calendar for the patient to read. b. Use removable restraints like a roll-waist belt to prevent wandering. c. Approach the patient so that the nurse can be seen clearly. d. Place the patient in a room close to the nurses' station for frequent observation.

ANS: C The patient is likely afraid and cannot process being touched. While using a large clock and calendar is recommended for anyone who is confused, these devices will not prevent the patient from screaming when touched (A). Using restraints or putting the patient in a busy, noisy environment like the nurses' station is likely to increase unwanted behaviors (B and C). Instead, the best action is to approach the client calmly so that he or she can see the nurse before the nurse begins to provide care.

A family member asks the nurse about whether there would be any long-term psychological effects from a client's mild traumatic brain injury. What is the nurse's best response? a. "You need to talk with the client's primary health care provider." b. "Usually any effects last for only a few weeks or months." c. "Each person's reaction to brain injury is different." d. "You should expect a change in the client's personality."

ANS: C While it is important to refer the client to the primary health care provider (A), the best response is to be realistic and explain that each person reacts differently to a mild TBI. Many clients experience some type of cognitive or emotional change(s), but some do not. Therefore, C is the best option.

A client who sustained a recent cervical spinal cord injury reports feeling flushed. His blood pressure is 180/100. What is the nurse's best action at this time? a. Perform a bladder assessment. b. Insert an indwelling urinary catheter. c. Turn on a fan to cool off the patient. d. Place the client in a sitting position.

ANS: D The client is likely experiencing autonomic dysreflexia which is caused by an uncontrolled sympathetic nervous system response to one or more triggers, such as bladder distention, constipation, and temperature variations. However, until the nurse can assess and manage the cause, the best action is to make sure to sit the patient up to begin lowering the blood pressure and prevent further increase.

Which are risk factors for stroke? (Select all that apply) A. High Blood Pressure B. Previous stroke or transient ischemic attack (TIA) C. Smoking D. Use of oral contraceptives E. Female Gender

ANS> A, B, C, D Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives. Other risk factors include high blood pressure and history of a previous TIA.Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms.

The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? A. "I should spend all my time with my husband in case I'm needed." B. "My husband may get depressed." C. "My husband must take his medicine every day to prevent another stroke." D. "The physical therapist will show us how to use the equipment so my husband can climb the stairs and get into and out of bed."

Ans A. "I should spend all my time with my husband in case I'm needed." Further home care teaching is needed when the stroke client's wife says that "I need to spend all my time with my husband in case I'm needed." Although well intentioned, family members can start to feel socially isolated when caring for a loved one. The family may need to plan for regular respite care in a structured day-care respite program or through relief provided by a friend or neighbor.The life changes associated with stroke often cause a change in the client's self-esteem. The client who has had a stroke needs to maintain a regular medication regimen to help prevent another stroke. If it is determined necessary after a home assessment, the physical and occupational therapist will show the client and family how to use equipment so they are able to mobilize and function in the home setting.

An hour later, the patient is crying because of severe joint pain in her hands. What are your priority actions at this time?

Assess the patient level of pain, check for pain medication orders, and PRN meds Reassess her pain level after administration of pain medication.

A client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching? A. "It is important to post my medicine schedule at home, so my family knows my schedule." B. "I can continue to take over-the-counter drugs like before." C. "An extra supply of medicine must be kept in my car." D. "Wearing a watch with an alarm will remind me to take my medicine."

B. "I can continue to take over-the-counter drugs like before." Further teaching about medication administration is indicated when the client with MG says that he/she can still take over-the-counter drugs. Clients with MG must not take any over-the-counter medications without checking with their primary health care provider first.The client's medication schedule may be posted in the home for the benefit of family members. An extra supply of medication should be kept in the client's car or workplace to maintain therapeutic levels in case a dose was missed. The client may wear a watch with an alarm as a medication reminder to maintain therapeutic levels.

What is the priority nursing assessment when a patient is admitted to the PACU? A. Level of consciousness B. Airway and gas exchange C. Dressing and incision status D. Vital signs and body temperature

B. Airway and gas exchange. When admired to APCu the first assessment should be patient airway and gas exchange. The other choices are second to patent airway.

The patient is admitted to the orthopedic unit. On assessment, the nurse notes that the patient has loss of motor function, pain, and temperature sensation below the level of injury. Sensations of touch, position, and vibration are intact. Which spinal cord syndrome does the nurse suspect? A. Central cord syndrome B. Anterior cord syndrome C. Posterior cord syndrome D. Brown-Séquard syndrome

B. Anterior Cord syndrome a decrease in blood supply to the anterior white mater results in a loss of motor function, pain, and temperature sensation below the level of injury. However sensations of touch, position, and vibration remain intact. Some of these patients motor control is recovered.

The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign/symptom is the nurse most concerned about? A. Amnesia B. Asymmetric pupils C. Headache D. Head laceration

B. Asymmetric pupils The nurse is most concerned about asymmetric pupils in the client with traumatic brain injury. Asymmetric (uneven) pupils are treated as herniation of the brain from increased intracranial pressure (ICP) until proven otherwise. The nurse must report and document any changes in pupil size, shape, and reactivity to the primary health care provider immediately.Amnesia, a headache and a head laceration, can be signs of mild traumatic brain injuries and need to be investigated more thoroughly.

While the patient is monitored in the ED, which finding will the nurse immediately report to the provider? A. Unresolved headache B. Blood pressure of 90/70 mm Hg C. Neck pain of "5" on a 0-to-10 scale D. Increase in the Glasgow Coma Scale score

B. Blood pressure of 90/70 mm Hg. -Low systolic BP can indicate a decrease in perfusion to the spinal cord. A headache may linger. Neck pain if the chief complaint. but is likely to resolve completely in ED. An increase in the coma scale would indicate improvement in a patents condition.

A patient with a TBI has nonreactive and dilated pupils. What would the nurse anticipate? A.Loss of vision B.Brain stem herniation C.Intense headache D.Projectile vomiting

B. Brain stem herniation Uneven pupils, loss of light reaction, unilateral or bilateral dilated pupils are related as herniation of the brain from ICP until proven differently. Fixed pupils are a prognostic sign and often referred to as having blown pupils.

A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How does the nurse help the client compensate? A. Approaches the client on the affected side B. covers the affected eye C. Encourages turning the head from side to side D. Places objects in the client's field of vision

B. Covers the affected eye The nurse helps the stroke client compensate with double vision by covering the affected eye. Covering the client's affected eye with a patch prevents diplopia.The client who is recovering from a stroke would always be approached on the unaffected side. The nurse may encourage side-to-side head turning for clients with hemianopsia (blindness in half of the visual field). Objects would be placed in the field of vision for the client with a decreased visual field.

The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the primary health care provider (PHCP) will request which medication to aid in the diagnosis of MG? A. Atropine B. Edrophonium chloride (Tensilon) C. Methylprednisolone (Solu-Medrol) D. Ropinirole (Requip)

B. Edrophonium chloride (Tensilon) The nurse expects the PHCP to request edrophonium chloride for a newly admitted client suspected of having MG. Edrophonium chloride (Tensilon) and neostigmine bromide (Prostigmin) may be used for testing for MG. Tensilon is used most often because of its rapid onset and brief duration of action. This drug inhibits the breakdown of acetylcholine (ACh) at the postsynaptic membrane, which increases the availability of ACh for excitation of postsynaptic receptors.Atropine has parasympatholytic effects and is the antidote for edrophonium chloride. Methylprednisolone (Solu-Medrol) is a glucocorticoid that is used to treat inflammatory disorders. Ropinirole (Requip) is a dopamine agonist used in the treatment of restless leg syndrome (RLS).

A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke? A. A-V-P-U B. F-A-S-T C. K-I-N-D D. O-P-Q-R-S-T

B. F-A-S-T The mnemonic F-A-S-T is utilized to teach the client, family, and community how to recognize and respond to a stroke. The purpose is to observe the Face, Arms, Speech, and then Time of onset and knowing it's Time to call 9-1-1.A-V-P-U is the mnemonic for level of awareness (alert, verbal, painful, and unresponsive). K-I-N-D is a mnemonic for treatment of hyperkalemia (kayexalate, insulin, NaHCO3, diuretics). O-P-Q-R-S-T is a mnemonic for assessing pain (onset, provokes, quality, radiates, severity, time).

A patient with a spinal cord injury at C5-C6 reports a sudden severe headache. The patient is flushed. Vital signs include a blood pressure of 190/100 mm Hg and heart rate of 52 beats/min. What is the priority nursing intervention? A. Notify the health care provider. B. Place the patient in a sitting position. C. Check the patient for fecal impaction. D. Check the urinary catheter for kinks or obstruction.

B. Place the patient in a sitting position. autonomic dysreflexia is an excessive, uncontrolled sympathetic output and is a neurologic emergency in patients with spinal cord injury T6 and above. The first priority of care is to place the patient in a sitting position than contact the health care provider to treat the increased blood pressure.

When assessing the laboratory work of a 65-year-old patient scheduled for surgery, the nurse understand which laboratory value may result in cancellation of the surgery? A. Hemoglobin 10.5 g/dL B. Serum potassium 2.7 mEq/L C. Serum sodium level 149 mEq/L D. Fasting blood glucose 120 mg/dL

B. Serum Potassium Slows recovery from anesthesia, increases cardiac irritability. Must be corrected before surgery

The patient's ankle heals, and his cast is removed. What teaching will the nurse provide regarding care for his ankle? A. "Scrub your lower leg and ankle to remove dead, scaly skin." B. "Wear a support stocking to prevent lower extremity swelling." C. "Keep your ankle in a low position to facilitate perfusion to the healed bone." D. "Exercise vigorously at least three times a day as directed by the physical therapist."

B. Wear support socking to prevent swelling. Ankle should be supported, dead skin should be soaked off not scrubbed, exercises should be done slowly.

The patient's wife must leave her husband's bedside for 2 hours to run errands. Which nursing action is appropriate to contribute to patient safety while she is gone? A. Apply restraints. B. Maintain the bed in a low position. C. Sit with the patient until his wife returns. D. Place the call light in the patient's right hand.

B. restraints should not be applied until all alternate method have been attempted. Sitting with a patient for 2 hours is impractical. Call light in the right hand would not be helpful because of the right visual field deficits.

The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

B> Young adult who has experienced four tonic-clonic seizures within the past 30 minutes After receiving report on a group of clients, the nurse first needs to attend to the young adult client who is experiencing repeated seizures over the course of 30 minutes. This client is in status epilepticus, which is a medical emergency and requires immediate intervention.The adult client who is lethargic and the middle-aged adult client with absence seizures do not require immediate attention. A fever of 101.9° F (38.8° C), although high, does not require immediate attention.

The patient is a 63-year-old woman admitted to the acute medical care unit. She is 5ʹ4ʺ and weighs 211 lbs. Her medical history includes hypertension and GERD. On admission, she reports pain in her hands and joints that is unrelieved by OTC medications. What additional assessment data should you collect from the patient at this time?

Based on age and reports of pain the patient is most likely experiencing osteoarthritis. This may be caused by her weight. It is important to know when the pain started and ask her to rate her pain 0-10. which OTC has she taken? how long has she experienced this pain? does she have any family history?

Thirty minutes later, the wife asks for a glass of water or juice because her husband is thirsty. What is the nurse's best response?

Before the patient is given any liquid, food, or medications he must be screened for the ability to swallow, his gag and cough reflexes must be checked. After swallow screening and it's safe he can tolerate liquids or food without aspirating fluids and food will be provided.

If patient has a shell-fish allergy what would you suspect they are also allergic to?

Betadine Allergy.

The patient needs assistance with feeding, but can swallow well. To whom should the nurse delegate this responsibility? A. Hospital volunteer B. Licensed practical nurse C. Certified nursing assistant D. Student nurse doing first patient care experience

C. Certified nursing assistant. -Feeding patients falls within the scope of practice for a CNA.

The spouse of a patient brought to the ED states that 6 hours ago her husband began having difficulty finding words. The patient has since become progressively worse. He has right hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position and has been incontinent of urine. What is the priority nursing intervention for this patient at this time? A. Provide perineal care. B. Assess for gag reflex. C. Elevate the head of the bed. D. Perform a linen and gown change.

C. Elevate the head of the bed. -Airway must be protected, then everything else can follow.

The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving intravenous immunoglobulin (IVIG). Which assessment finding warrants immediate evaluation? A. Chills B. Generalized malaise C. Headache with stiff neck D. Temperature of 99.

C. Headache with stiff neck Immediate evaluation is needed when a client with GBS receiving IVIG complains of a headache with stiff neck. This may be a sign of aseptic meningitis, a possible serious complication of IVIG therapy.Chills, generalized malaise, and a low-grade fever are minor adverse effects of IVIG therapy and do not indicate that the therapy must be stopped.

Your patient has a history of epilepsy. While helping the patient to the restroom, the patient reports having this feeling of déjà vu and seeing spots in their visual field. Your next nursing action is to? A. Continue assisting the patient to the restroom and let them sit down B. Initiate the emergency response system C. Lay the patient down on their side with a pillow underneath the head D. Assess the patient's medication history

C. Lay the patient down on their side, with a pillow under the head. -Visual changes and resorts of feeling deja vu means seizure is likely occurring soon. Side lying reduces risk of aspiration, and pillow provides comfort if they seize.

The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? A. Dexamethasone (Decadron) B. Hydrochlorothiazide (HydroDIURIL) C. Mannitol (Osmitrol) D. Phenytoin (Dilantin)

C. Mannitol (Osmitrol) In a postoperative craniotomy client with ICP, the nurse expects Mannitol to be requested to keep the ICP within a certain range. Mannitol is an osmotic diuretic used specifically to treat cerebral edema.Glucocorticoids have no demonstrated benefit in reducing ICP. Hydrochlorothiazide is only a mild diuretic and is not beneficial in maintaining ICP. Dilantin is used to treat seizure activity caused by increased ICP.

A client has Parkinson's disease (PD). Which nursing intervention best protects the client from injury? A. Discouraging the client from activity B. Encouraging the client to watch the feet when walking C. Monitoring the client's sleep patterns D. Suggesting that the client obtain assistance in performing activities of daily living (ADLs)

C. Monitoring the client's sleep patterns The nursing intervention that best protects the PD client from injury is to monitor the client's sleep patterns. Clients with PD tend to not sleep well at night because of drug therapy and the disease itself. Some clients nap for short periods during the day and may not be aware that they have done so. This sleep misperception could put the client at risk for injury (e.g., falling asleep while driving).Active and passive range-of-motion exercises, muscle stretching, and activity are important to keep the client with PD mobile and flexible. The client with PD needs to avoid watching his or her feet when walking to prevent falls and would be encouraged to participate as much as possible in self-management, including ADLs. Occupational and physical therapists can provide training in ADLs and the use of adaptive devices, as needed, to facilitate independence.

A client arrives in the emergency department with new-onset ptosis, diplopia, and dysphagia. The nurse anticipates that the client will be tested for which neurologic disease? A. Bell's palsy B. Guillain-Barré syndrome (GBS) C. Myasthenia gravis (MG) D. Trigeminal neuralgia

C. Myasthenia gravis (MG) The nurse expects the client with these signs/symptoms will be tested for MG. Sudden-onset ptosis, diplopia, and dysphagia are classic signs/symptoms of MG. Laboratory studies and a cholinesterase inhibitor test (e.g., Tensilon challenge test) most likely will be done to confirm the diagnosis.Signs/symptoms of Bell's palsy include facial paralysis; the face appears masklike and sags. Signs/symptoms of GBS typically begin in the legs and spread to the arms and upper body. Trigeminal neuralgia is characterized by sharp, intense facial pain that is usually not associated with sensory or motor deficits.

A patient is newly diagnosed with osteoarthritis (OA). Which teaching is most appropriate for the nurse to include? A. OA is an immune disorder B. OA is always degenerative C. OA can be aggravated by obesity D. OA is a systemic disease

C. OA can be aggravated by obesity. -OA is not always degenerative, not an immune disorder or systemic disorder this is associated with rheumatoid arthritis. Weight-bearing joints such as hops, and need are most often affected in obese people.

Patient states that he was jogging close to the edge of a hillside, and that he tripped and fell down the hill. There are no openings in the skin. A pulse cannot be obtained by touch to the right foot, which is pale and cool to palpation. The patient rates his pain as an "8" on a 0-to-10 scale. What is the priority nursing action at this time? A. Prepare for reduction. B. Administer pain medication. C. Obtain a Doppler of the right foot pulse. D. Notify the physician of the lack of a pulse in the right foot.

C. Obtain Doppler of right foot pulse. Doppler should be done to confirm lack of pulse, then notify the physician.

A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client? A. Calling the stroke team B. Establishing an IV C. Positioning the client to prevent aspiration D. Preparing for thrombolytic administration

C. Positioning the client to prevent aspiration Positioning the client while maintaining cervical spine immobilization to prevent aspiration is the nurse's priority intervention. Maintaining a patent airway is essential especially since this client is vomiting.Calling the Stroke Team would not be necessary. Establishing an IV is important for this client but it is not the first priority. If this client was having a stroke, thrombolytics would be contraindicated because of the fall with head strike.

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure. B. Forces a tongue blade in the mouth. C. Positions the client on the side. D. Restrains the client.

C. Positions the client on the side. When a newly admitted client with a history of seizures begins to seize, the nurse must turn the client on his/her side. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness resulting in potential loss of a patent airway.Documenting the length and time of seizures is important, but not the priority intervention. Both forcing a tongue blade in the mouth and restraining the client can cause injury.

A client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention does the nurse perform first? A. Calls the Rapid Response Team (RRT) to intubate B. Instructs the client on how to cough effectively C. Raises the head of the bed to 45 degrees D. Suctions the client

C. Raises the head of the bed to 45 degrees The nurse's first action for a client with an exacerbation of GBS who now has dyspnea is to raise the head of the bed to 45 degrees. The head of the client's bed must be elevated to allow for increased lung expansion. This action helps improve the client's ability to breathe.Calling the RRT for intubation may be necessary if dyspnea is severe or oxygen saturation does not respond to oxygen therapy. Close monitoring of respiratory status is indicated because of the acute stages of GBS. Instructing the client on how to cough effectively is not the priority in this case. The client would be suctioned as needed but cautiously to avoid vagal stimulation.

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? A. Encouraging nutrition B. Frequent ambulation C. Regular turning and repositioning D. Special pressure-relief devices

C. Regular turning and repositioning Regular turning and repositioning are the best way to prevent complications of immobility in clients with spinal cord problems.A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Frequent ambulation may not be possible for these clients. Use of special pressure-relief devices is important but is not the best way to prevent immobility complications.

Two hours later, laboratory values are drawn to investigate the patient's symptoms. The results are -Sodium 136 mEq/L -HCT 41.6% -Potassium 4.6 mEq/L -HGB 12.8 g/dL -Calcium 8.9 mg/dL -ESR 28 mm/hr -Are any of these results of concern?

CBC and electrolytes are within normal limits. The ESR is high-normal which is common with osteoarthritis.

A patient has a new order for open magnetic resonance imaging (MRI) to evaluate for right femur osteomyelitis. Which information obtained by the nurse indicates that the nurse should consult with the health care provider before scheduling an MRI? A. The patient is claustrophobic. B. The patient wears a hearing aid. C. The patient is allergic to shellfish. D. The patient has a pacemaker.

D. patients with pacemakers cannot have MRi an open MRI will not cause claustrophobia. Remove hearing aids before MRI. Contract will not be used to allergy is not a contraindication.

What health history question will give the nurse the most information when evaluating a patient for Guillain-Barré syndrome (GBS)? A."Did you get a flu vaccine in the past year?" B."Has anyone else in your family ever had GBS?" C>"Have you ever been exposed to Epstein-Barr virus?" D."Have you had a respiratory virus in the past 2 weeks?"

D. usually GBS occurs a few days or weeks after the patients has has symptoms of a respiratory or GI viral infection. Surgery can trigger the syndrome. In rare instances vaccinations may increase GBS risk. This disorder can develop over the course of hours or days or 3-4 weeks.

The nurse is teaching the spouse and client who has had a brain attack about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction? A. "Frequent stimulation will help with the rehabilitation process." B. "My spouse will no longer need to take blood pressure medication." C. "Rehabilitation and physical therapy are the same thing." D. "The rehabilitation therapist will help identify changes needed at home."

D. "The rehabilitation therapist will help identify changes needed at home." Understanding instructions about brain attack is demonstrated by the statement that the rehabilitation therapist will help identify any needed home changes. The rehabilitation therapist and home health professionals assist the client and family in adapting the home environment to the client's needs and assess the client's need for therapy.An appropriate amount of stimulation based on the client's needs will be determined by the therapist and incorporated into a comprehensive plan. Any medication regimen established for the client after the brain attack must be maintained. Rehabilitation is much more comprehensive than physical therapy.

The patient is admitted to the acute medical unit after 7 hours. His wife asks if her husband will receive IV thrombolytic therapy. What is the nurse's best response?

Patients must meet strict eligibility criteria for thrombolytic therapy with rtPA, including giving the drug within 3 hours after the first stroke symptoms.