Exam 3 Past Quizzes

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Slow, fearful performance of tasks B. Overestimation of physical abilities C. Difficulty judging position and distance D. Impulsivity and impatience at performing tasks

A. Slow, fearful performance of tasks

The nurse reviews a client's arterial blood gas results and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mmol/L), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? A. Respiratory alkalosis, compensated B. Metabolic acidosis, compensated C. Metabolic alkalosis, uncompensated D. Respiratory acidosis, uncompensated

A. Respiratory alkalosis, compensated

The patient with diabetes had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of patient' s mouth

A. Safety measures

A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The healthcare provider calls and asks for a report on the client's condition. Based on the documentation below (ICP >16), how would the nurse respond? A. "The client's ICP remains elevated." B. "The client's ICP has decreased to lower than normal limits." C. "The client's ICP is within normal limits." D. "The client's ICP was elevated but now has returned to normal."

A. "The client's ICP remains elevated."

A client with 3-day history of N/V presents to the ED. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn, and the nurse reviews the results, expecting to note which finding? A. An increased pH and an increased HCO3- B. A decreased pH and a decreased HCO3- C. An increased pH and a decreased Paco2 D. A decreased pH and an increased Paco2

A. An increased pH and an increased HCO3-

During an initial shift assessment, a nurse finds a diabetic client who is lethargic and who has rapid, deep respirations. Which priority action should the nurse take? A. Elevate the head of bed above 30 degrees. B. Start oxygen at 2 L/min as needed. C. Administer a saline bolus as needed. D. Contact the healthcare provider.

A. Elevate the head of bed above 30 degrees.

The nurse is caring for a patient with severe metabolic alkalosis. Which intervention is the highest priority? A. Ensure the upper side rails of the patient's bed are up. B. Administer intravenous NaHCO3 as ordered. C. Teach the family about metabolic alkalosis. D. Measure the urine output and skin turgor.

A. Ensure the upper side rails of the patient's bed are up.

How does a client compensate for metabolic acidosis? A. Hyperventilation B. Renal retention of H+ C. Hypoventilation D. Renal excretion of HC03

A. Hyperventilation

A client presents to the walk-in clinic, reporting that he has been vomiting "off and on" for the past 24 hours. The nurse is aware that this client is at risk for which of the following complications? A. Hypokalemia & metabolic alkalosis B. Hyperkalemia & metabolic acidosis C. Hypokalemia & metabolic acidosis D. Hyperkalemia & metabolic alkalosis

A. Hypokalemia & metabolic alkalosis

The nurse is preparing to administer mannitol as ordered for a client with cerebral edema and increased intracranial pressure. The nurse is aware that mannitol should be administered to this client via which route? A. Intravenously B. Intramuscular C. Intraosseously D. Orally

A. Intravenously

A CT scan of a patient' s head reveals a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. Maintaining the patient' s airway B. Positioning to promote cerebral perfusion C. Controlling fluid and electrolyte imbalances D. Administering tissue plasminogen activator (tPA)

A. Maintaining the patient' s airway

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance? A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis

A. Respiratory acidosis

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions? (Select all that apply.) A. Ticlopidine B. Clopidogrel C. Enoxaparin D. Dipyridamole E. Enteric-coated aspirin F. Tissue plasminogen activator (tPA)

A. Ticlopidine B. Clopidogrel D. Dipyridamole E. Enteric-coated aspirin

A client with chronic renal failure is experiencing metabolic acidosis. The client most likely requires: A. no treatment. B. sodium bicarbonate supplements. C. hemodialysis. D. peritoneal dialysis.

A. no treatment.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? A. pH 7.25, Paco2 50 mm Hg B. pH 7.35, Paco2 40 mm Hg C. pH 7.50, Paco2 52 mm Hg D. pH 7.52, Paco2 28 mm Hg

A. pH 7.25, Paco2 50 mm Hg

Nurse is caring for client with NG tube ordered for low intermittent suction. The nurse finds the NG tube is on continuous suction. Nurse immediately changes the suction back to low, intermittent suction. Client confused, nervous, tremors in hands (all new assessments) Nurse reports findings to HCP, who orders the NG suction to be stopped for now and orders a set of ABGs. Which ABGs does the nurse expect? A. pH 7.48, PC02 30, HC03 32 B. pH 7.32, PC02 50, HC03 28 C. pH 7.48, PC02 30 D. HC03 20

A. pH 7.48, PC02 30, HC03 32

The nurse, who is caring for a client who recently presented to the emergency room, suspects the client is in metabolic alkalosis. Which arterial blood gas values best validate this condition? A. pH 7.51, PC02 48, HC03 34 B. pH 7.23, PC02 58, HC03 26 C. pH 7.58, PC02 22, HC03 23 D. pH 7.38, PC02 50, Hc03 30

A. pH 7.51, PC02 48, HC03 34

The nurse is assessing a client for a possible brainstem herniation. Which findings assist in confirming this diagnosis? Select all that apply. A. respiratory rate decreased from 14 to 10 breaths per minute and irregular B. blood pressure increased from 118/70 to 140/82 mmHg C. urine output decreased from 45 to 30 mL/hour D. body temperature decreased from 97.8°F (36.5°C) to 96.9°F (36.1°C) E. heart rate increased from 80 to 120 beats per minute

A. respiratory rate decreased from 14 to 10 breaths per minute and irregular B. blood pressure increased from 118/70 to 140/82 mmHg

If it is determined that a patient has experienced a simple febrile seizure the next course of action is: A. Obtain outpatient brain MRI without contrast B. Lumbar puncture C. No further imaging D. Provide educational and emotional support E. Both C and D

E. Both C and D

Which patient should the nurse closely monitor for the risk factors of metabolic acidosis? A. A patient diagnosed with acute meningococcal meningitis B. A patient with a pancreatic fistula that is draining C. A patient with severe hyperaldosteronism D. A patient with Type B chronic obstructive pulmonary disease (COPD) and pneumonia

B. A patient with a pancreatic fistula that is draining

Which is the priority goal of the treatment plan when providing care to a patient who has just experienced a stroke? A. Adequate urine output B. Blood pressure management C. Oral hypoglycemic to maintain blood sugar between 120 and 150 mg/dL D. Monitor swallowing function.

B. Blood pressure management

Nurse is assigned to client with right-sided hemiparesis from stroke. Which characteristics are associated with this condition? SATA A. Client has lost ability to ambulate independently but can feed and bathe himself without assistance. B. Client is aphasic. C. Client has weakness on right side of the body. D. Client has complete bilateral paralysis of arms and legs. E. Client has weakness on right side of face and tongue. F. Client has lost ability to move right arm but can walk independently.

B. Client is aphasic. C. Client has weakness on right side of the body. E. Client has weakness on right side of face and tongue.

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include? A. Belief that the current surroundings are a racetrack. B. GCS score was "11" one hour ago C. Recent vitals = BP 120/80, HR 82 D. Reported allergy to penicillin and vancomycin

B. GCS score was "11" one hour ago

Nurse returns call from parent whose teenager experienced hard tackle. Parent says, "He seemed dazed after and coach had him sit out rest of game, he's fine now." What's most appropriate instruction for nurse to give? A. Take him immediately to the emergency department B. He can't return to play until he has been evaluated by a health care provider C. If he seems fine now and has had no other symptoms, it probably was not a concussion D. Watch him closely and call us back if you see any changes

B. He can't return to play until he has been evaluated by a health care provider

Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? A. Alcohol use B. Hypertension C. Hyperlipidemia D. Oral contraceptive use

B. Hypertension

The nurse would expect what assessment finding in a patient admitted with a left-sided stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span

B. Impaired speech

The nurse is assessing a patient diagnosed with DKA. The assessment reveals tachycardia, lethargy, and hyperventilation. Treatment for the ketoacidosis has been initiated. What should the nurse do about the hyperventilation? A. Request an order for pain medication and oxygen at 6 L/min. B. Lubricate the patient's lips and allow continued hyperventilation. C. Have the patient breathe into a paper bag to stop hyperventilating. D. Contact the physician immediately regarding this complication.

B. Lubricate the patient's lips and allow continued hyperventilation.

Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel and a compound fracture of the right tibia and fibula and multiple lacerations and contusions. What is the priority nursing goal for this client? A. Reduce the client's anxiety. B. Maintain adequate oxygenation. C. Decrease chest pain. D. Maintain adequate circulating volume.

B. Maintain adequate oxygenation.

Which pathology is caused by a partially occluding clot and is preceded by stroke-like symptoms that usually resolve in under an hour and are not identifiable on Computerized Tomography (CT) of the brain? A. Embolic CVA B. Trans Ischemic Attack (TIA) C. Thrombotic CVA D. Hemorrhagic CVA

B. Trans Ischemic Attack (TIA)

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do? A. Pivot on the left foot to the chair placed on the patient's left. B. Use a transfer belt C. Keep the feet close together D. Bend at the waist

B. Use a transfer belt

Nurse has instructed family of a client with a recent stroke and hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? A. "We need to place objects in his impaired field of vision." B. "We need to discourage him from wearing eyeglasses." C. "We need to remind him to turn his head to scan the lost visual field." D. "We need to approach him from the impaired field of vision."

C. "We need to remind him to turn his head to scan the lost visual field."

The nurse in a primary care provider ' s office is assessing several patients today. Which patient is most at risk for a stroke? A. A 92-yr-old female patient who takes warfarin for atrial fibrillation B. A 28-yr-old male patient who uses marijuana after chemotherapy to ease nausea C. A 72-yr-old male patient who has hypertension and diabetes and smokes tobacco. D. A 42-yr-old female patient who takes oral contraceptives and has migraine headaches

C. A 72-yr-old male patient who has hypertension and diabetes and smokes tobacco.

A patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? A. Position the patient on her weak side most of the time. B. Avoid the use of pillows to promote independence in positioning. C. Alternate the patient' s positioning between supine and side-lying. D. Establish a schedule for the massage of areas where skin breakdown emerges

C. Alternate the patient' s positioning between supine and side-lying.

When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/VN? A. Screen patient for tPA eligibility. B. Assess the patient' s ability to swallow. C. Give scheduled anticoagulant medications. D. Place seizure precaution equipment in room.

C. Give scheduled anticoagulant medications.

The home care nurse is visiting a male client who is recovering at home after suffering a cerebral vascular accident 2 weeks ago. The client's wife states that the client has difficulty feeding himself. Which would be the initial nursing action? A. Make the patient NPO and call the Speech Therapist. B. Observe the wife feeding the client. C. Observe the client feeding himself. D. Instruct the wife in the use of a feeding syringe to feed the client.

C. Observe the client feeding himself.

A client with an acute head injury cannot accurately identify the sensation felt when the nurse touches the intact skin with a cotton ball or paper clip. The nurse is aware that the deficit reflects injury to which area of the brain? A. Occipital B. Frontal C. Parietal D. Temporal

C. Parietal

Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? A. Present several thoughts at once so the patient can connect the ideas. B. Ask open-ended questions to give the patient the opportunity to speak. C. Use simple, short sentences with visual cues to enhance comprehension. D. Finish the patient' s sentences to minimize frustration associated with slow speech

C. Use simple, short sentences with visual cues to enhance comprehension.

A patient is experiencing their first severe, acute asthma episode. The episode began 2 hours ago. What blood gas values should the nurse expect? A. pH high, PaCO2 high, HCO3− high B. pH high, PaCO2 low, HCO3− low C. pH low, PaCO2 high, HCO3− normal D. pH low, PaCO2 high, HCO3− high

C. pH low, PaCO2 high, HCO3− normal

The nurse is planning psychosocial support for the family of the patient who had a stroke. What factor will have the greatest impact on family coping? A. specific patient neurological defects B. the patients ability to communicate C. rehabilitation potential of the patient D. presence of complications of a stroke

C. rehabilitation potential of the patient

The nurse observes a student nurse assigned to start oral feedings for a patient with an ischemic stroke. Which action by the student will require the nurse to intervene? A. Giving the patient 1 ounce of water to swallow B. Telling the patient to perform a chin tuck before swallowing C. Assisting the patient to sit in a chair before feeding the patient D. Assessing cranial nerves III, IV, and VI before attempting feeding

D. Assessing cranial nerves III, IV, and VI before attempting feeding

Nurse is caring for a client who is in chronic phase of stroke and has right-sided hemiparesis. Nurse identifies that patient is unable to feed themselves. Which is the appropriate nursing intervention? A. Provide a pureed diet that is easy for the client to swallow. B. Provide a variety of foods on the meal tray to stimulate the client's appetite. C. Inform the client that a feeding tube will be placed if progress is not made. D. Assist the client to eat with the left hand to build strength.

D. Assist the client to eat with the left hand to build strength.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? A. Fluid is clear and tests negative for glucose. B. Fluid is grossly bloody in appearance and has a pH of 6. C. Fluid clumps together on the dressing and has a pH of 7. D. Fluid separates into concentric rings and tests positive for glucose.

D. Fluid separates into concentric rings and tests positive for glucose.

A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? A. Assist the patient to the bathroom every 2 hours. B. Provide incontinence briefs to wear during the day. C. Give a bisacodyl (Dulcolax) rectal suppository every day. D. Provide several servings daily of cooked fruits and vegetables.

D. Provide several servings daily of cooked fruits and vegetables.

A female patient presents to the emergency department reporting the most severe headache of her life. Which type of stroke should the nurse anticipate? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage

D. Subarachnoid hemorrhage

A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? A. Difficulty speaking or writing name B. Has trouble swallowing secretions C. Has slurred speech D. The patient has decreased reading comprehension

D. The patient has decreased reading comprehension

Which questions should the nurse ask when assessing for risk factors for metabolic acidosis? (Select all that apply.) A. Have you been vomiting today? B. What type of antacid did you take? C. Are you still feeling short of breath? D. When did your kidneys stop working? E. How long have you had diarrhea? F. Which weight loss diet are you using?

D. When did your kidneys stop working? E. How long have you had diarrhea? F. Which weight loss diet are you using?