Complex Unit 4
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? 1. Current medications. 2. Complete physical and history. 3. Time of onset of current stroke. 4. Upcoming surgical procedures.
3. Time of onset of current stroke. The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. Option 1: Current medications are relevant, but the onset of current stroke takes priority. Option 2: A complete history is not possible in emergency care. Option 4: Upcoming surgical procedures will need to be delay if t-PA is administered.
The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? A. Vision changes B. Absent deep tendon reflexes C. Tremors at rest D. Flaccid muscles
A. Vision changes Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis.
Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia? A. Rice cereal, whole milk, and yellow vegetables B. Potato, peas, and chicken C. Macaroni, cheese, and ham D. Pudding, green vegetables, and rice
B. Potato, peas, and chicken Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron.
The primary purpose of the Schilling test is to measure the client's ability to: A. Store vitamin B12 B. Digest vitamin B12 C. Absorb vitamin B12 D. Produce vitamin B12
C. Absorb vitamin B12 Pernicious anemia is caused by the body's inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schilling's test helps diagnose pernicious anemia by determining the client's ability to absorb vitamin B12.
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: 1. Pulse 2. Respirations 3. Blood pressure 4. Temperature
3. Blood pressure Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the priority is blood pressure.
Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.
1. A 55-year-old African American male. African Americans have twice the rate of CVA's as Caucasians; males are more likely to have strokes than females except in advanced years. Option 2: Oriental's have a lower risk, possibly due to their high omega-3 fatty acids. Option 4: Pregnancy is a minimal risk factor for CVA.
Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.
1. Placing the client on the back with a small pillow under the head. A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. Option 2: It may be necessary to suction, so having suction equipment at the bedside is necessary. Option 3: Padded tongue blades are safe to use. Option 4: A toothbrush is appropriate to use.
A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance? A. "What activities were you able to do 6 months ago compared to the present?" B. "How long have you had this problem?" C. "Have you been able to keep up with all your usual activities?" D. "Are you more tired now than you used to be?"
A. "What activities were you able to do 6 months ago compared with the present?" It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client's activity tolerance by asking the client to compare activities 6 months ago and at the present. Option B: Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client's activity tolerance. Also, the client may not even identify that a "problem" exists. Option C: Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Option D: Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.
A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse's best response? A. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid." B. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." C. "The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction." D. "The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."
B. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. Options A, C, and D: The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in this condition.
A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan? A. "Take the medication with an antacid." B. "Take the medication with a glass of milk." C. "Take the medication with cereal." D. "Take the medication on an empty stomach."
D. "Take the medication on an empty stomach." Preferably, ferrous gluconate should be taken on an empty stomach. Options A, B, and C: Ferrous gluconate should not be taken with antacids, milk, or whole-grain cereals because these foods reduce iron absorption.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Cholesterol level 2. Pupil size and pupillary response 3. Bowel sounds 4. Echocardiogram
2. Pupil size and pupillary response It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Option 1: Cholesterol level is an assessment to be addressed for long-term healthy lifestyle rehabilitation. Option 3: Bowel sounds need to be assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours. Option 4: An echocardiogram is not needed for the client with a thrombotic stroke.
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dl. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mmHg. 4. The presence of bronchogenic carcinoma
3. A blood pressure of 220/120 mmHg. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel in the cranium. Option 1: High blood glucose levels could predispose a patient to ischemic stroke, but not hemorrhagic. Option 2: Bruit in the carotid artery would predispose a client to an embolic or ischemic stroke. Option 3: Cancer is not a precursor to stroke.
The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? A. Whole grains B. Green leafy vegetables C. Meats and dairy products D. Broccoli and Brussels sprouts
C. Meats and dairy products Good sources of vitamin B12 include meats and dairy products. Option A: Whole grains are a good source of thiamine. Option B: Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Option D: Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination D. Risk for injury
B. Ineffective airway clearance In Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they aren't immediately life-threatening.
Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? A. An elevated hemoglobin level B. A decreased reticulocyte count C. An elevated RBC count D. Red blood cells that are microcytic and hypochromic
D. Red blood cells that are microcytic and hypochromic The results of a CBC in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated
The nurse is preparing to teach a client with iron-deficiency anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? A. Eggs B. Lettuce C. Citrus fruits D. Cheese
A. Eggs A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Options B and C: Dark green leafy vegetables and citrus fruits are good sources of vitamin C. Option D: Cheese is a good source of calcium.
The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: A. The client has complete bilateral paralysis of the arms and legs. B. The client has weakness on the right side of the body, including the face and tongue. C. The client has lost the ability to move the right arm but can walk independently. D. The client has lost the ability to move the right arm but can walk independently
B. The client has weakness on the right side of the body, including the face and tongue. Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is a weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition
A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: A. Getting too little exercise B. Taking excess medication C. Omitting doses of medication D. Increasing intake of fatty foods
C. Omitting doses of medication Myasthenic crisis often is caused by under medication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Option B: Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Options A and D: Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger
The nurse is caring for the male client who begins to experience seizure activity while in beD. Which of the following actions by the nurse would be contraindicated? A. Loosening restrictive clothing B. Restraining the client's limbs C. Removing the pillow and raising padded side rails D. Positioning the client to side, if possible, with the head flexed forward
B. Restraining the client's limbs The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.
Which of the following blood components is decreased in anemia? A. Erythrocytes B. Granulocytes C. Leukocytes D. Platelets
A. Erythrocytes Anemia is defined as a decreased number of erythrocytes (red blood cells). Option B: Granulocytopenia is a decreased number of granulocytes (a type of white blood cells). Option C: Leukopenia is a decreased number of leukocytes (white blood cells). Option D: Thrombocytopenia is a decreased number of platelets.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta-blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.
1. An oral anticoagulant medication. Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge versus intravenous.
A male client is having tonic-clonic seizures. What should the nurse do first? A. Elevate the head of the bed. B. Restrain the client's arms and legs. C. Place a tongue blade in the client's mouth. D. Take measures to prevent injury.
D. Take measures to prevent injury. Protecting the client from injury is the immediate priority during a seizure.
The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: A. Eating large, well-balanced meals B. Doing muscle-strengthening exercises C. Doing all chores early in the day while less fatigued D. Taking medications on time to maintain therapeutic blood levels
D. Taking medications on time to maintain therapeutic blood levels Taking medications correctly to maintain blood levels that are not too low or too high is important.
A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurse's first response? A. Assess for potential abuse B. Check for diminished sensations C. Document the findings D. Clean and dress the area
B. Check for diminished sensations Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain. Option A: The burn could be related to abuse, but this conclusion would require more supporting data. Option C: The findings should be documented, but the nurse would want to address the client's sensations first. Option D: The decision of how to treat the burn should be determined by the physician.
The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? A. Schilling's test elevated B. Intrinsic factor, absent. C. Sedimentation rate, 16 mm/hour D. RBCs 5.0 million
B. Intrinsic factor, absent. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Option A: Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. Option C: A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. Option D: An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.
A vegetarian client was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: A. Adds dried fruit to cereal and baked goods B. Cooks tomato-based foods in iron pots C. Drinks coffee or tea with meals D. Adds vitamin C to all meals
C. Drinks coffee or tea with meals Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Option A: Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Option B: Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Option D: Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for A STAT computer tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.
3. Schedule for A STAT computer tomography (CT) scan of the head. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use rt-PA. This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated. Option 1: rt-PA is contraindicated. Options 2 and 4: Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching. Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol.
The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? A. Giving the client thin liquids B. Thickening liquids to the consistency of oatmeal C. Placing food on the unaffected side of the mouth D. Allowing plenty of time for chewing and swallowing
A. Giving the client thin liquids Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. Option B: Liquids are thickened to avoid aspiration. Option C: Food is placed on the unaffected side of the mouth. Option D: The client is assisted with meals as needed and is given ample time to chew and swallow.
