Adult health exam 5
A client with a metastatic brain tumor of the frontal lobe experiences a generalized seizure for the first time. The nurse should prepare for what action?
administration of anticonvulsants
A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize which action?
removing all metal containing objects
A client has experienced burns to the upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?
pulses
The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this client's care?
risk for falls
An older adult client is being discharged home. The client lives alone and has atrophy of the olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home?
smoke detector
The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication?
Provide a board of commonly used needs and phrases.
A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning the client's care, the nurse would expect to administer what priority medication?
mannitol
A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment component is most important?
"Does anyone in your family have eczema or psoriasis?"
A hearing impaired client is scheduled to have an MRI. What would be important for the nurse to remember when caring for this client?
Patient is likely unable to hear the nurse during test.
The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient
MS is a progressive demyelinating disease of the nervous system.
A middle-aged client has sought care from the primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the client to seek care?
difficulty in coordination
The nurse has created a plan of care for a patient who is at risk for increased ICP. The patient's care plan should specify monitoring for what early sign of increased ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex
disorientation and restlessness
Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when
every 2 hours
The nurse is caring for a client who has a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?
generalized pain
A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?
generalized seizure
An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows thatthe patient is at increased risk for what complication of his injury
hematoma
A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who iscreating a care plan. What nursing diagnosis is most likely for a patient with this condition?
impaired verbal communication
A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood?
A. The client is likely experiencing a delayed onset of respiratory complications
A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. Whatmedication would the nurse expect the physician to order for the treatment of this disease process?
Acyclovir (Zovirax)
The nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)?
Assess the client's eye opening and response to stimuli.
The nurse's assessment of a client with significant visual losses reveals that the client cannot count fingers. How should the nurse proceed with assessment of the client's visual acuity?
B) Determine whether the patient is able to see the nurse's hand motion.
The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke?
C) Aspirin 81 mg PO o.d.
A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose?
C) To remove atherosclerotic plaques blocking cerebral flow
A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should the nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply
Diabetic retinopathy Glaucoma Macular degeneration
A 25-year-old female patient with brain metastases is considering her life expectancy after her most recent meeting with her oncologist. Based on the fact that the patient is not receiving treatment for her brain metastases, what is the nurse's most appropriate action?
Ensuring that the patient receives adequate palliative care
A client comes to the clinic reporting a red rash of small, fluid filled blisters and is suspected of having herpes zoster. What presentation is most consistent with this diagnosis?
Grouped vesicles in linear patches along a dermatome
What neurological assessment should the nurse perform to gauge the client's function of cranial nerve I?
Have the client identify familiar odors with the eyes closed
A group of high school adolescents is attending a concert, which will be at a volume of 80 to 90 db. What is a health consequence of this sound level?
Hearing loss may occur with a decibel level in this range.
A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury?
Pad the side rails of the patient's bed.
The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in the education?
Take antihypertensive medication as prescribed.
A nurse is working with a family whose 5-year old child has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care?
Teaching about the importance of maintaining high standards of hygiene
A hospital client has experienced a seizure. In the immediate recovery period,what action best protects the client's safety?
a. Place the client in a side-lying position.
The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? select all that apply
apnea coma absence of deep tendon reflexes
The emergency room (ER) nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment findings are suggestive of a basilar skull fracture? Select all that apply.
bruising over the mastoid
An unresponsive client with a light complexion has brought to the emergency room by EMS. While assessing this client, the nurse notes that the clients face is a cherry red color. What should the nurse suspect?
carbon manoxide
An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of the burn?
causative agent
The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis?
monitor serum electrolytes
The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient?
monitoring neurologic status closely
A new client has come to the dermatology clinic to be assessed for a reddened rash on the abdomen. For what diagnostic test should the nurse prepare the client to identify the causative organism?
patch testing
A nurse practitioner is seeing a 16-year-old client who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications?
peroxide
A patient, diagnosed with cancer of the lung, has just been told he has metastases to the brain. Whatchange in health status would the nurse attribute to the patient's metastatic brain disease?
personality changes
A client presents to the clinic reporting a headache. The nurse notes that the client is guarding the neck and tells the nurse about stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection?
positive kernig's sign
A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care?
surgical intervention
