Adult Health II - exam 3 NCLEX questions
A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? a) Prepare the patient for opening or bivalving of the cast. b) Obtain an order for a different analgesic. c) Encourage the patient to wiggle and move the fingers. d) Petal the edges of the patient's cast.
A
In evaluating an HIV-positive patient's responses to antiviral therapy, which data indicates a positive response? Increased CD4 count Increased BUN Increased viral load Increased creatine
A
The client is in skeletal traction with 20lb of traction applied to a right lower leg fracture. Which intervention should the nurse perform at regular intervals? Perform pin care Remove the weights Reposition the right leg Have the client perform active ROM exercise on their legs
A
When discussing physical activities with the client who has just undergone a right total hip replacement, which instruction should the nurse provide? a) "Limit hip flexion to 90 degrees." b) "Perform rotation exercises each day." c) "Intermittently cross and uncross your legs several times each day." d) "Avoid weight bearing until the hip is completely healed."
A
•In order to prevent the development of shoulder pain during recovery from a stroke, the nurse should: a. Avoid contact with the patient's weak arm whenever possible b. Avoid taking the patient's blood pressure on the affected arm c. Support the patient's weak arm on a pillow or table d. Let the patient's weak arm hang loose whenever possible
C
•Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared for a cervical fracture. Which action is the nurse's PRIORITY when receiving the client in the ED? •A. Assessing the client using the GCS. •B. Assessing the level of sensation in the client's extremities •C. Checking that the cervical collar was correctly placed by EMS •D. Applying antiembolism hose to the client's lower extremities
C
The client, diagnosed with an ischemic stroke, is being evaluated for thrombolytic therapy. Which assessment finding should prompt the nurse to withhold thrombolytic therapy? A. Brain CT scan results show no bleeding B. Had a serious head injury 3 weeks ago C. Has a history of type 1 diabetes mellitus (DM) D. Neurological deficits started 2 hours ago
B
The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene? a) Body aligned opposite to line of traction pull b) Weights hanging and touching the floor c) Pulleys without evidence of the obstruction d) Ropes freely moving over pulleys
B
The nurse is screening patients for the risk of developing HIV infections and providing appropriate counseling. The considers which patient at greatest risk? A white male with a history of multiple heterosexual partners A Black male with a history of sex with men A white female with a history of multiple blood transfusions A Black female with a history of intravenous drug use
B
The client, who recently had a stroke, follows the nurse's instructions without problems, but an attempt to verbally respond to the nurse's questions was garbled. The nurse should identify that the client has which type of aphasia? A. Receptive aphasia B. Global aphasia C. Expressive aphasia D. Anomic aphasia
C
The community health nurse is conducting a health promotion program at a local school and is discussing cancer risk factors. Which of the following, if indicated as a risk factor by the client indicates a need for further education? Viruses Sedentary lifestyle Low fat, high fiber diet Exposure to radiation
C
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. A blood glucose level of 480 mg/dL B. A right sided carotid bruit C. A blood pressure (BP) of 220/110 mm HG D. The presence of bronchogenic carcinoma
C
•A patient sustained a C6 SCI 4 hours ago. Which of the following nursing diagnoses is a priority? •A. Urinary retention •B. Risk for impaired skin integrity •C. Ineffective breathing pattern •D. Powerlessness
C
A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA) B. Discuss the precipitating factors that caused the symptoms C. Schedule for a STAT computed tomography (CT) scan of the head D. Notify the speech pathologist for an emergency consult
C
The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis? X-ray of the femur Serum alkaline phosphatase Dual-energy x-ray absorptiometry (DEXA) Serum calcium levels
C
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement FIRST? A. Notify the health-care provider immediately B. Prepare to administer an antihistamine C. Test the drainage for presence of glucose D. Place a 2 x 2 gauze under the nose to collect drainage
C
A physician diagnoses primary osteoporosis in a client who has lost bone mass. In this metabolic disorder, the rate of bone resorption accelerates while bone formation slows. Primary osteoporosis is most common in: a) elderly men. b) young children. c) young menstruating women. d) elderly postmenopausal women.
D
The client who has engaged in needle-sharing activities has developed a flu-like infection. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding? The client must be repeatedly exposed to HIV before becoming infected. The antibody test is negative because the client has a different flu virus. The client is fortunate not to have contracted HIV from an infected needle. The client may be in the primary infection phase of an HIV infection.
D
The nurse is caring for a client 6 hours postoperative right total knee replacement. Which data should the nurse report to the surgeon? A total of 50 mL of serosanguinous drainage in the Hemovac Drain Pain relief after using the PCA pump Cool toes, distal pulses palpable, nail beds pale bilaterally- cap refill less than 3 seconds Urine output of 30 mL of dark amber colored urine in 3 hours.
D
You're educating a patient about transient ischemic attacks (TIAs). What statement by the patient indicates a need for further education? A. TIAs are caused by a temporary decrease in blood flow to the brain B. TIAs produce symptoms that can last for a few minutes up to a few hours C. A TIA is a warning sign that a stroke might occur D. TIAs do not require medical treatment
D
Modes of transmission for HIV include blood, semen, saliva, and casual contact. True or False
False
The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV) with a CD4 count of less than 200 cells/ul. The nurse documents this as which stage of infection? Pre-HIV Stage 2 Stage 3 Stage 1
Stage 3
•Which of the following initial diagnostic tests is performed when a stroke is suspected? a. MRI b. Noncontrast CT c. CT with contrast d. Cerebral angiography
b
The nurse is developing a care plan for a client who has had chemo and radiation therapy for Hodgkin's lymphoma. Which is the primary goal for this client? Maintain fluid balance Obtain sufficient exercise Prevent Infection Avoid depression
c
A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure? a) Administering large doses of oral antibiotics as ordered b) Instructing the client to ambulate twice daily c) Withholding all oral intake d) Administering large doses of I.V. antibiotics as ordered
d
•Which of the following would the nurse expect to document in the patient diagnosed with a right hemispheric stroke? a. Aphasia b. Slow, cautious behavior c. Right visual field defect d. Impulsive behavior
d
