Exam 2
A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?
Remind the client to look for food on the left side of the tray.
A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?
Risk for acquiring an infection
A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client?
Rotate the clients meal tray when the client stops eating.
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion?
Turn off oxygen therapy.
A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura?
Visual disturbance - Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura.
The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included?
Women may experience extreme fatigue and dizziness as sole symptoms.
Which drug for symptomatic bradycardia does the nurse prepare to administer to a patient with bradydysrhythmia?
atropine
A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. currently the client's neurologic examination is normal. about what drug would the nurse plan to teach the patient?
Clopidogrel
The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse?
Collaborate with the health care provider to administer a positive inotropic agent.
A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
Compare the results with previous pulmonary artery pressure readings.
A patient reports chest pain and dizziness after exertion, and the family reports a concurrent new onset of mild confusion in the patient, as well as difficulty concentrating. What is the priority problem for this patient?
Decreased cardiac output
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client?
Ensure the balloon does not remain wedged.
A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?
Establish a plan of care with the client that sets attainable goals.
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goal should the nurse include in the clients rehabilitation program?
Establish the ability to communicate effectively.
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?
Evaluate respiratory status. -The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.
A nurse is caring for a client who has a hemorrhagic stroke. The nurse knows that which of the following is the most concerning.
Hypertension - High BP with hemorrhagic strokes are concerning for causing increased amount of brain bleeding. Hypertension is the most common cause of hemorrhagic stroke.
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?
I will avoid sources of strong electromagnetic fields
A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?
Impulse behavior
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?
Inability to recognize his family members
A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. Which action should the nurse take first?
Assess the clients medications.(POSSIBLE CAUSE FOR LOW HR/WHAT SHOULD NOT BE GIVEN)
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best?
Assess the clients sodium level.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
Assess the color and temperature of the left leg.
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take next?
Assess vital signs and level of consciousness.
A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client?
Assess whether or not the client can write.
A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply.)
- Until your incision is healed, do not submerge your pacemaker. Only take showers. -Do not lift your left arm above the level of your shoulder for 8 weeks. -Report any pulse rates lower than your pacemaker settings.
Which actions are the responsibilities of the monitor tech? (SATA)
- Watch the bank of monitors on a unit -Print routine ECG strips -Interpret the rhythms - Report patient rhythm and significant changes to the nurse
Which clinical manifestations are reflections of sustained tachydysrhythmias?
- chest discomfort -palpations -syncope -restlessness
The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching?
" This test evaluates you for potentially fatal cardiac rhythms "
Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial?
" i don't need to change. it hasn't killed me yet
A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alert the nurse to possible viral meningitis? (Select all that apply.)
- clear -increased protein level -normal glucose level
A nurse is caring for a patient who has had a myocardial infarction. Upon his first visit to the cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response? Cardiac rehabilitation cannot undo the damage to your heart.
"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely"
A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the clients nutritional needs. Which response by the nurse is appropriate?
"He is NPO until the speech-language pathologist performs a swallowing evaluation."
A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered "a test on my heart" how should the nurse respond?
"Most of these types of blood clots come from the heart"
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.)
- Accompanied by shortness of breath -Feelings of fear or anxiety -No relief from taking nitroglycerin -Pain occurs without known cause
A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.)
- Advanced age - Diabetes -Ethnic background - Smoking
The nurse is taking the initial history and vital signs on a patient with fatigue. The nurse notes a regular apical pulse of 130 beats/min. Which contributing factors does the nurse assess for? (select all that apply)
- Anxiety or stress - Fever - Hypovolemia - Anemia or hypoxemia
A patient has had synchronized cardioversion for unstable VT. Which interventions does the nurse include in the patients care after the procedure? (select all that apply)
- Assess vital signs and the level of consciousness. - Administer antidysrhythmic drug therapy -Monitor for dysrhthmias -Assess for chest burns from electrodes
Excessive vagal simulation can result form which activities? (select all that apply)
- Carotid sinus massage - Suctioning -Valsalva maneuver - Bearing down as if having a BM
Which signs and symptoms are seen with suspected pericarditis? (Select all that apply.)
- Chest pain relieved by sitting upright -Sudden-onset chest pain relieved by anti-inflammatory agents - Pain in the chest described as sharp or stabbing
A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.)
- Decrease in cardiac output - Increase in blood pressure - Decrease in urine output
Which of these factors contribute to the risk for cardiovascular disease? (Select all that apply.)
- Elevated C-reactive protein levels - smoking
A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.)
- Hoarseness -Dysphagia
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.)
- Hypertension - Obesity - Smoking - Stress
What are the risk factors for AF? (select all that apply)
- Hypertension -Diabetes mellitus -Valvular disease - Excessive alcohol use
A patient has no pulse and the cardiac monitor shows VF. Which drugs does the nurse prepare to administer during the resuscitation? (select all that apply)
- Lidocaine -Epinephrine -Amiodarone hydrochloride (Cordarone) -Magnesium sulfate
Based on the prevalence and risk factors for atrial fibrillation (AF), which patient group is at highest risk for AF?
- Older adults
Which are characteristics of angina? (SATA)
- Pain is precipitated by exertion or stress - Pain is relieved by nitroglycerin or rest - Pain lasts less than 15 minutes
A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.)
- Prepare for continuous blood pressure and pulse monitoring. - Give the client nothing by mouth 3 to 6 hours before the procedure. - Explain to the client that dobutamine will simulate exercise for this examination.
A patient is diagnosed with recurrent supra-ventricular tachycardia (SVT). What does the nurse do in order to accomplish the preferred treatment?
- Provide information about radiofrequency catheter ablation therapy.
A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching? (Select all that apply.)
- Smoking cessation -Stress reduction and management -Adverse effects of medications
Which laboratory findings are consistent with acute coronary syndrome (ACS)? (Select all that apply.)
- Troponin 3.2 ng/mL - Myoglobin 234 mcg/L
. A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.)
-Dilated pupils -Widened pulse pressure -Bradycardia
An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.)
-Fatigue despite adequate rest, Indigestion, shortness of breath -Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.
The patient has sustained SVT and the health care provider orders IV adnosine. Which important actions must the nurse perform when this drug is given? ( select all that apply)
-Have emergency equipment at the bedside. - Follow the drug injection with a normal saline bolus. - Monitor the patient for bradycardia, nuasea, and vomiting
. A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.)
-Serum potassium of 2.9 mEq/L -Expanding groin hematoma -Rhythm changes on the cardiac monitor
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)
-Thrombophlebitis -Pulmonary embolism -Cardiac tamponade
The nurse is caring for several patients in the telemetry unit who are being remotely watched by a monitor technician. What is the nurse's primary responsibility in the monitoring process of these patients?
Assessment and management of pts
A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation?
A 50-year-old who is post coronary artery bypass graft surgery
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?
A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
A nurse is developing a plan of care for a client who has a spinal fracture and a complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the clients plan of care?
Ability to self-feed with the use of adaptive equipment
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure?
Allergies to iodine-based agents
A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the client's record. What action by the nurse is best?
Ask the client how long ago the clip was placed.
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate?
Assess for any hemodynamic effects of the rhythm.
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?
Assess the client for bleeding. (PATIENT COULD BE HEMORRHAGING
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate?
Avoid straining while having a bowel movement.
The nurse is interviewing a patient who suddenly becomes faint, immediately loses consciousness, and becomes pulseless and apneic. There is no blood pressure, and heart sounds are absent. The RN has called for help. What does the nurse do next?
Begin compressions.
A patient has been admitted for acute angina. Which diagnostic test identifies if the patient will benefit from further invasive management after acute angina or an MI?
Cardiac catheterization
A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?
Clear drainage from nose
A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg
A nurse is caring for four clients. Which client should the nurse assess first?
Client who is 1 hour post angioplasty, has tongue swelling and anxiety
A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first?
Client with a Glasgow Coma Scale score that was 10 and is now is 8
Which client is exhibiting signs of MI?
Client with pressure in the mid-abdomen and profound diaphoresis
The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client?
Decreased level of consciousness - The earliest sign of increasing ICP is decreased level of consciousness. The other signs occur later.
The nurse has four patients on telemetry monitors and is analyzing the ECG rhythm strips for assigned pts. What is her 1st action?
Determine the heart rate
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
Disorientation and confusion - In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction
A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met?
Has clear lung sounds on auscultation. - Impaired swallowing can lead to aspiration and then aspiration pneumonia, so the expected outcome for this problem is to experience no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate that the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.
A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect?
Heart rate of 120 beats/min - When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client may not be able to compensate for long and decreased oxygenation and cool, clammy skin will occur later.
A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best?
Inform the student that the docusate should be given.
A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first?
Initiate Oxygen Therapy
The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the health care provider?
Intravenous furosemide.
The nurse is caring for several patients who have dysrhythmia. What does the nurse instruct these patients to do?
Learn the procedure for assessing the pulse.
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?
Level of consciousness
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer?
Lorazepam (Ativan) - Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.
The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs?
Mean arterial pressure (MAP) is 58 mm Hg. -Mean arterial pressure (MAP) is 58 mm Hg. Correct To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. A MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain. An arterial line will not measure atrial pressure, PAWP, or oxygenation. Normal right atrial pressure is 1 to 8 mm Hg. Normal PAWP is 4 to 12 mm Hg. A normal PO2 is greater than 75 mm Hg.
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?
Midsternal chest pain - Chest pain, possibly angina, indicates that tachycardia may be increasing the clients myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and would be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.
The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client?
Needs frequent re-orientation
A patient had surgery for repair of an arteriovenous malformation (AMV). The patient is now reporting a severe headache and has vomited. What action by the nurse take priority?
Notify the Rapid Response Team.
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take?
Notify the health care provider before scheduling the MRI.
A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?
Palpate the bladder for distention. (COM PROBABLY SAVERED)
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
Perform a 12-lead ECG.
The intensive care nurse is monitoring a patient with a right ventricular MI. The pulmonary artery wedge pressure (PAWP) reading is 30 mm Hg. What does the nurse do next?
Perform an ECG using right-sided precordial leads
A client recovering from cardiac angiography develops slurred speech. What does the nurse do first?
Performs a complete neurologic assessment and notifies the health care provider
A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client?
Poor prognosis and cognitive function
A patient with AF suddenly develops shortness of breath, chest pain, hemoptysis, and a feeling of impending doom. The nurse recognizes these symptoms as which complication?
Pulmonary embolism
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
Slurred speech and confusion (INTELLELCT/LANGUGE/COMMUNICATION
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best?
Stop the infusion and call the provider.
A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client's score to be 36. How should the nurse plan care for this client?
The client will need near-total care.
The respiratory therapist (RT) and the medical student are ventilating a patient in cardiac arrest, while the nurse and provider are preparing the patient and equipment for intubation. At which point does the nurse intervene?
The medical student sets the oxygen flow meter at 2 L/min
A nurse in an ED is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to administer?
Tissue plasminogen activator (tPA)
a client is receiving IV alteplase and reports a sudden severe headache. what is the nurse first action
administer an antihypertensive drug -A severe headache may indicate that the clients blood pressure has markedly increased and, therefore, the drug should be stopped immediately as the first action. The nurse would then perform the appropriate assessments and possibly administer an antihypertensive medication.
A client is admitted with a sudden decline in level of consciousness. what is the nursing action at this time ?
assess the client for hypoglycemia and hypoxia. Brain needs sugar and oxygen
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?
d. Prepare to administer a fluid bolus.
Which early reaction is most common in patients with chest discomfort associated with unstable angina or MI?
denial
A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history?
fatigue
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
i get shortness of breath when i climb stairs - Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.
A client who is to undergo cardiac catheterization should be taught which essential information by the nurse?
keep your affected leg straight for 2 to 6 hours
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?
maintain airway patency.
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response?
short period of asystole
a client with a stroke is being evaluated for fibrinolytic therapy. what information from the client or family is most important for the nurse to obtain
time of symptoms onset
