Exam 2 Practice

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.) 1.Hypotension 2.Polyuria 3.Hypoglycemia 4.Absence of bowel sounds 5. Weakened gag reflex

1. Hypotension 4. Absence of bowel sounds 5. Weakened gag reflex Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal cord. Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client to develop a paralytic ileus. Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.

A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. which of the following findings should the nurse immediately report to the charge nurse? 1 edematous bruise on forehead 2 small drops of clear fluid in left ear 3 client disoriented to place 4 heart rate 110/min and regular

2 small drops of clear fluid in left ear Small drops of clear fluid from the ear are likely cerebrospinal fluid (CSF), which indicates that this client is at greatest risk for meningitis. Following a basilar skull fracture, a tear in the meninges can allow CSF to escape. Fluid might be noted in the ear canals or from the nose. The nurse should report this finding immediately.

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? 1.Tachycardia 2.Amnesia 3.Hypotension 4.Restlessness

4. Restlessness Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern (early indicator)

A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.) A. Check peripheral pulses in the affected extremity. B. Place the client in high-Fowler's position. C. Measure the client's vital signs every 4 hr. D. Keep the client's hip and leg extended. E. Have the client remain in bed up to 6 hr

A, D, E Check peripheral pulses in the affected extremity is correct. The nurse should check pulse points plus skin temperature and color in the affected extremity as prescribed by the facility, which is commonly every 15 min for 1 hr, every 30 min for 1 hr, and hourly for 4 hr. Place the client in high-Fowler's position is incorrect. The client should remain flat or with the head of the bed elevated no more than 30&deg for 2 to 6 hr after the procedure. Measure the client's vital signs every 4 hr is incorrect. The nurse should measure the client's vital signs frequently, with each check of the affected extremity. Keep the client's hip and leg extended is correct. The nurse should keep the client from flexing the knee or hip and can use a knee brace to prevent bending the affected leg. Have the client remain in bed up to 6 hr is correct. Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest

A nurse is caring for a client following the insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure? A. "I can't get rid of these hiccups." B. "I feel dizzy when I stand." C. "My incision site stings." D. "I have a headache

A. "I can't get rid of these hiccups." "I can't get rid of these hiccups."Rationale: Hiccups indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? A. Defibrillation B. Airway management C. Epinephrine administration D. Amiodarone administration

A. Defibrillation The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm

A nurse in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. the nurse should identify that which of the following factors can cause a myasthenic crisis? A. Developing a respiratory infection B. Taking too much prescribed medication C.Insufficient sleep D. Insufficient exercise

A. Developing a respiratory infection The most common triggers of a myasthenic crisis is a respiratory infection as a result of not taking or taking too little of the prescribed medication. Surgery and pregnancy are also triggers

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions? A. Elective cardioversion B. Defibrillation C. CPR D. Radiofrequency catheter ablation

A. Elective cardioversion This is the priority intervention when the client is awake and responsive. Ventricular tachycardia might not be an immediate threat to the client, but it does require intervention to prevent long-term cardiac impairment

A nurse is assessing for the presence of extrapyramidal side effects (EPSs) in a client taking chlorpromazine (Thorazine). Which of the following findings should the nurse recognize as EPSs? Select all that apply. A. Muscle contractions of the neck B. Fidgeting behavior C. Fluctuating vital signs D. Impaired gait E. Sexual dysfunction

A. Muscle contractions of the neck B. Fidgeting behavior D. Impaired gait

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take? A. Prepare the client for mechanical ventilation B. Administer an anticholinesterase medication. C. Instruct the client to perform the pursed lip breathing. D. Prepare to administer a vasoconstrictor.

A. Prepare the client for mechanical ventilation

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take? A. Prepare the client for mechanical ventilation. B. Administer an anticholinesterase medication. C. Instruct the client to perform the pursed lip breathing. D. Prepare to administer a vasoconstrictor.

A. Prepare the client for mechanical ventilation.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? A. Provide client supervision. B. Limit client physical activity. C. Speak loudly to the client. D. Leave the television on continuously.

A. Provide client supervision.

. A nurse enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first? A. Summon the code team B. Begin chest compressions C. Administer rescue breathing D. Open the client's airway

A. Summon the code team After determining that the client is in respiratory or cardiac arrest the nurse should first summon the code team before initiating CPR.

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? A. Test the drainage for glucose. B. Suction the nostril. C. Notify the physician. D. Ask the client to blow his nose

A. Test the drainage for glucose. This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF, which will test positive for glucose

A nurse is caring for a client who is receiving chlorpromazine (Thorazine) and is given a pass to attend a family outing on a sunny day. Which of the following is the most important for the nurse to include in the client's teaching about the side effects of chlorpromazine? A. Wear a hat and a long-sleeved shirt. B. Suck on hard candies. C. Drink plenty of fluids. D. Limit alcoholic beverages to one beer only

A. Wear a hat and a long-sleeved shirt. Photophobic skin reactions and damage to the retina of the eye can occur when a client who is taking chlorpromazine is expose to direct sunlight. Clients should be reminded to wear protective clothing, apply sunscreen, and wear sunglasses.

a nurse is collecting data from a client who has a traumatic head injury which of the following findings should the nurse report to the provider immediately? A. sudden sleepiness B. diplopia C. headache D. slight ataxia

A. sudden sleepiness A client who has sudden sleepiness is unstable due to the increase in intracranial pressure. Therefore, the nurse should report this finding to the provider immediately.

A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? A. Slow repolarization of ventricular Purkinje fibers B. Atrial depolarization C. Early ventricular repolarization D. Ventricular depolarization

B. Atrial depolarization

A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis lab findings should the nurse anticipate? A. absence of glucose B. Decreased specific gravity C. Presence of Ketones D. presence of RBCs

B. Decreased specific gravity The urine of a client with DI will be dilute and less than 1.005

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? A. Different blood pressures in the upper limbs. B. Different apical and radial pulses. C. Differences between oral and axillary temperatures. D. Differences in upper and lower lung sounds

B. Different apical and radial pulses. Atrial fibrillation is rapid, disorganized electrical activity of the heart in which the atrium depolarizes too quickly and sends erratic impulses to the ventricles. The presence of a pulse deficit between the apical and radial pulses is an indication of atrial fibrillation. The nurse should assess further by obtaining an ECG or telemetry reading

A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? A. Anorexia B. Dyspnea C. Fever D. Malaise

B. Dyspnea When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority manifestation to monitor for is dyspnea. Dyspnea can be an indication of left-sided heart failure, or a pulmonary infarction due to embolization.

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions? A. Defibrillation B. Elective cardioversion C. CPR D. Radiofrequency catheter ablation

B. Elective cardioversion Elective cardioversion is the priority intervention when the client is awake and responsive. Ventricular tachycardia might not be an immediate threat to the client, but it does require intervention to prevent long-term cardiac impairment

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? A. Engage in a vigorous exercise program. B. Implement a schedule to include periods of rest. C. Wear an eye patch on the right eye at all times. D. Plan to relax in a hot tub spa each day."

B. Implement a schedule to include periods of rest.

A nurse is caring for a client diagnosed with myasthenia gravis. Which of the following findings indicates the client is experiencing an advanced symptom of this disease? A. Confusion B. Incontinence C. Headache D. Hypertension

B. Incontinence Bowel and bladder incontinence is associated with advanced cases of myasthenia gravis

A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings? A. Decreased heart Rate B. Increased hematocrit C. High urine specific Gravity D. Decreased BUN

B. Increased hematocrit An increased hematocrit level is an expected finding related to dehydration increased urine output leads to dilute urine and a LOW urine specific gravity' Tachycardia is an expected finding of diabetes insipidus Increased in BUN relates to dehydration

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? A. Increased cardiac output B. Increased pulmonary congestion C. Decreased left atria pressure D. Decreased pulmonary artery pressure

B. Increased pulmonary congestion Pulmonary congestion occurs due to right-sided heart failure. Because of the defect in the mitral valve, the left atrial pressure rises, the left atrium dilates, there is an increase in pulmonary artery pressure, and hypertrophy of the right ventricle occurs. In this case, dyspnea is an indication of pulmonary congestion and right-sided heart failure.

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion? A. Sudden lethargy. B. Muffled heart sounds C. Flattened neck veins. D. Bradycardia.

B. Muffled heart sounds Muffled heart sounds are a key indicator of cardiac tamponade because of the excess amount of fluid surrounding the heart.

Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload? A. Mean arterial pressure (MAP) B. Systemic vascular resistance (SVR) C. Pulmonary vascular resistance (PVR) D. Pulmonary artery wedge pressure (PAWP)

B. Systemic vascular resistance (SVR) ANS: 2Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly.

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? A. Confusion B. Weakness C. Increased intracranial pressure D. Increased urinary output

B. Weakness

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make? A. Why do feel that you need to leave?" B. You feel that you don't belong here?" C. We are here to help you and give you the care that you need right now." D. Try to take some deep breaths and I'm sure you'll feel better.

B. You feel that you don't belong here?" Restating is a therapeutic communication technique and encourages further dialogue.

A nurse caring for a client at risk for increased intracranial pressure monitors the client for manifestations that indicate the pressure is increasing. The nurse should check the function of the third cranial nerve by A. observing for facial asymmetry. B. checking pupillary response to light C. eliciting the gag reflex D. esting visual acuity.

B. checking pupillary response to light Cranial nerve III, the oculomotor nerve, is responsible for pupillary response to light

A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.) A. Delusions B. Hallucinations C. Anhedonia D. Poor judgment: E. Blunt affect

C, E Both Anhedonia and Blunt effect are negative symptoms of schizophrenia

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification? A. Morphine sulfate 2mg IV bolus every 2hr PRN pain B. Laboratory testing of serum potassium upon admission C. 0.9% Normal saline IV at 50ml/hr continuous D. Bumetanide 1mg IV bolus every 12 h

C. 0.9% Normal saline IV at 50ml/hr continuous Rationale: 0.9% sodium chloride is isotonic and will not cause the fluid shift need in this client to reduce circulatory overload. This prescription requires

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication? A. Have the client empty his bladder. B. Put up the side rails on the client's bed. C. Ask the client to take a few sips of water. D. Place the client in low Fowler's position.

C. Ask the client to take a few sips of water.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestationsshould the nurse expect? A. Pruritus B. Hypertension C. Bradykinesia D. Xerostomia

C. Bradykinesia

A nurse is caring for a client who has valvular heart disease and is at risk for developing left sided heart failure. Which if the following manifestations should alert the nurse that the client is developing this condition? A. Anorexia B. Weight gain C. Breathlessness D. Distended Abdomen

C. Breathlessness Manifestation of left-sided heart failure includes crackles or wheezes and breathlessness due to pulmonary congestion

A client has a pulmonary artery wedge pressure (PAWP) reading of 15 mm Hg. Which of the following conditions might the nurse expect this finding to indicate? A. Fluid volume deficit B. Right ventricular failure C. Mitral regurgitation D. Afterload reduction

C. Mitral regurgitation Rationale: Expected PAWP readings are between 4 and 12 mm Hg. Elevated PAWP measurements may indicate hypervolemia, left ventricular failure, mitral regurgitation, or intracardiac shunt

A nurse is monitoring the pulmonary artery wedge pressure (PAWP) for a client. The nurse should identity that a reading of 15 mm Hg is an indication of which of the following conditions? A. Fluid volume deficit B. Right ventricular failure C. Mitral regurgitation D. Afterload reduction

C. Mitral regurgitation Rationale: Hemodynamic monitoring allows the nurse to monitor the pressures within the heart and the great vessels. The PAWP reflects left atrial pressure. A reading of 15 mm Hg is above the expected reference range, which can indicate mitral regurgitation, hypervolemia, or left ventricular failure. The nurse should monitor for trends in value, which can be more reliable than individual values

The ED nurse has just received a client from the ambulance service who's family said the client has had diarrhea for the last two days . Vital signs are BP 92/62, HR 107, temp. 99.6˚ F, O2 saturation 93% on room air. What is the priority nursing action? A. Start 0.9% NS @ 125mLs/hr B. Apply oxygen 2L via N/C C. Raise the head of the bed to 45 D. Start a 20g IV line

C. Raise the head of the bed to 45 Answer: Raise the head of the bed to 45˚. The nurse should raise the head of the bed first to allow for lung expansion and then apply oxygen via 2L N/C. If the client is lying flat, applying O2 first will not help them as much because of the inability to breathe properly. Lying flat on your back makes it difficult to breathe. The nurse can then start an IV, draw labs and start fluids. This client has fluid volume deficit from the diarrhea and the nurse should expect metabolic acidosis if an ABG is performed. Remember, if it comes out of the mouth (vomiting) they are losing acid, if it comes out the other end, they are losing base and will become acidotic

A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply) A. Flat jugular veins B. Glasgow Coma Scale score of 15 C. Sleepiness exhibited by the client D. Widening pulse pressure E. Decerebrate posturing

C. Sleepiness exhibited by the client D. Widening pulse pressure E. Decerebrate posturing Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP. A widening pulse pressure (increase in systolic with concurrent decrease in diastolic blood pressure) is an indication of increased ICP. Both decerebrate and decorticate posturing indicate increased ICP

A nurse is collecting data from a client who has parkinson's disease and is experiencing bradykinesia. Which of the following findings should the nurse expect? A. Increased blinking B. States of euphoria C. Slurred speech D. Decreased respiratory rate

C. Slurred speech The nurse should expect to observe slowed, slurred speech in a client who is experiencing bradykinesia

The nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities onthe client's EKG will the nurse interpret as a sign of hypokalemia? A. Peaked T waves B. Elevated ST segment C. Inverted P Waves D. Abnormally prominent U wave

D. Abnormally prominent U wave Answer: Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip fora flattened T wave, prolonged PR interval, prominent U wave, or ST depression.

A nurse is reinforcing discharge instruction with a client who has multiple sclerosis (MS) . which of the following instructions should the nurse include? A. Wait to perform difficult tasks until later in the day. B. Plan to relax in a hot tub spa each day. C. Limit your intake of dairy products. D. Implement a schedule to include periods of rest.

D. Implement a schedule to include periods of rest. The nurse should instruct the client to implement a schedule with periods of exercise followed by periods of rest to maintain muscle strength and coordination.

A nurse in a mental health facility is preparing to interview a client who is has schizophrenia. Which of the following actions should the nurse take? A. Sit on the other side of a table from the client. B. Place the client in a chair higher than the nurse. C. Start the interview with a question the client can answer with a "yes" or "no." D. Sit beside the client rather than facing him.

D. Sit beside the client rather than facing him. The nurse should sit beside the client or at a 90 angle from him so that direct eye contact is unnecessary. Sitting facing the client directly can cause him to feel uncomfortable and can make the interview is more intense

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal B. Troponin is a lipid whose levels reflect the risk for coronary artery disease C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. D. Troponin is a protein that helps transport oxygen throughout the body.

D. Troponin is a protein that helps transport oxygen throughout the body Troponin is a myocardial muscle protein that releases into the bloodstream when there is injury to the myocardial muscle. Troponin levels are specific point-of-care testing for clients who are having a myocardial infarction.

A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis?

Developing a respiratory infection

A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the following actions should the nurse include in the plan? a. Monitor the client's respirations every 4 hr. b. Administer an antacid with the medication to decrease nausea. c. Weigh the client daily. d. Monitor the client for signs of bleeding

a. Monitor the client's respirations every 4 hr. Chlorpromazine can cause respiratory depression, dyspnea, and laryngospasm.