Exam 4
You are caring for a patient with acute renal failure. What is the most common clinical manifestation of acute renal failure?
Oliguria
The order reads Dilantin 7 mg/Kg/ day for a child weighing 66 lbs. How many mg will be given daily?
210
What should be included in the patient's care plan when establishing an exercise program for a patient affected by a stroke?
Exercise the affected extremities passively four or five times a day
The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?
Facial droop
The nurse developing a plan of care for a patient with cardiomyopathy should include which of the following priority outcomes?
Improved cardiac output
The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patient's atmosphere more conducive to communication?
Provide a board of commonly used needs and phases
A patient comes to the clinic complaining of difficulty voiding. What nursing action should the nurse take to encourage a patient who is having difficulty voiding?
Provide privacy for the patient
Which ocular or facial sign/symptoms should the nurse expect to assess for the patient diagnosed with myasthenia gravis (MG)?
Ptosis and diplopia
The nurse is analyzing a patient's laboratory data. The ABGs are as follows pH 7.25, PaCO2 56 mm Hg, HCO# 24 mEq/L. This indicates:
Respiratory acidosis
The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patient's care plan?
Instruct the patient on daily muscle stretching.
A 48-year-old man diagnosed with amyotrophic lateral sclerosis, ALS, is having difficulty with swallowing. The family feels the patient has been choking and coughing excessively at mealtimes. The patient's temperature is elevated, his respiratory rate is 32 breaths/min, and he is using accessory muscles on inspiration. The nurse should make which of the following assessments?
Lung auscultation
The nurse is planning the care of a patient with chronic glomerulonephritis. What should be the goal of treatment for this patient?
Maintaining renal function
The client who just had a three (3)-minute seizure has no apparent injuries but is very lethargic and just wants to sleep. Which intervention should the nurse implement?
Turn the client to the side and allow the client to sleep
You are caring for an 84-year-old female patient who was brought to the emergency room by her family, who related that their mother has had mental status changes and periods of incontinence the past few days and they were very concerned. What condition would the nurse suspect the patient has?
Urinary tract infection
The nurse is planning discharge teaching for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to AVOID?
Washing the face
The order reads oral 1 1/2 teaspoon of Robitussin and you are using a 10mL syringe for measuring the oral dose. How many m/L will you give?
7.5
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse effects of this medication, the nurse should prioritize which of the following in the patient's plan of care?
Administration of thorough oral hygiene
When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke?
Alteration in level of consciousness
The patient has epilepsy and receives phenytoin (Dilantin). The patient has been seizure-free, and asks the nurse why he still needs blood tests when he is not having seizures. What is the best response by the nurse?
Because phenytoin (Dilantin) has a very narrow range between a therapeutic dose and a toxic dose
The nurse completing a health history on a newly diagnosed patient with generalized seizure disorder would assess for which of the following characteristics associated with the postictal state?
Confusion
A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform?
Position the patient upright during feeding.
A 55-year old male is admitted to the medical-surgical unit with the presumptive diagnosis of renal stones. While assessing the patient you note increased tenderness over the costovertebral area. The patient complains of increased pain and nausea, and then has an episode of vomiting. You know these symptoms are indicative of what?
Renal colic.
The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke? What content should the nurse include in this education?
Take antihypertensive medication as ordered
The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patient's chest and hears wheezing throughout the lung fields. What might this indicate?
The patient has a narrowed airway.
Which of the following patients are at an increased risk for oral problems? Select all that apply.
a patient undergoing, a comatose patient, a confused patient
The patient with a history of migraine headaches reports that a migraine is coming because she is experiencing bright spots before the eyes. Which phase of migraine headaches is the patient experiencing?
aura phase
Which of the following patients may require the use of an orthotic jacket to improve sitting stability and reduce trunk deformity resulting from a neurologic disorder?
A 14-year-old male with muscular dystrophy
The patient is 12 hours post lumbar laminectomy. Which nursing interventions should be implemented?
Assess ability to void and log roll the patient every two (2) hours
The patient diagnosed with cervical disk degeneration has undergone a cervical laminectomy. Which intervention should the nurse implement?
Assess the patient for difficulty speaking or breathing
A patient recently has been diagnosed with trigeminal neuralgia. Which intervention is most important for the nurse to implement with this patient?
Assist the patient to identify factors that trigger an attack
A female patient is admitted with an overdistended bladder. Which diagnostic test can be done to confirm the diagnosis of urine retention?
Bladder scan
To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine). What health education should the nurse provide to the patient before initiating this treatment?
Blood levels of the drug must be monitored.
A 37-year-old teacher is hospitalized with complaints of weakness, incoordination, dizziness, and loss of balance. The diagnosis is multiple sclerosis (MS). Which of the following signs and symptoms, revealed during the history and physical assessment, is typical of MS?
Blurred vision, intention tremor, and urinary hesitancy
A patient who just suffered a hemorrhagic stroke is admitted through the emergency room. The nurse's primary assessment is focused on:
Cardiac and respiratory status
A patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should the nurse identify as an expected outcome of this treatment?
Decreased muscle spasms in the lower extremities
The nurse is taking care of a patient who suffered a stroke and has a flaccid right arm and leg. He is experiencing urinary incontinence. The nurse is aware that the most common patient response to a change in body image is:
Depression
The patient with which of the following medical histories is at the greatest risk of developing end-stage renal disease (ESRD)?
Diabetes mellitus with poorly controlled hypertension
A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patient's care, the nurse addresses the need to enhance the patient's bladder control. What aspect of nursing care is most likely to meet this goal?
Establish a timed voiding schedule.
A patient is brought to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?
Evidence of a hemorrhagic stroke
A patient admitted with nephrotic syndrome is being cared for on your unit. When writing this patient's care plan, based upon the major clinical manifestation of nephrotic syndrome, what nursing diagnosis would you include?
Excess fluid volume related to generalized edema
The nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy. The nurse's plan of care should address what characteristic manifestation of this disease?
Facial paralysis
The nurse is caring for a patient recently diagnosed with myasthenia gravis whose CT scan reveals an enlarged thymus gland. Which additional assessment data would be consistent with the diagnosis of myasthenia gravis?
Generalized weakness of the extremities
The nurse is caring for a patient suspected of having renal dysfunction. When reviewing laboratory results for this patient the nurse recalls that several substances are filtered from the blood by the glomerulus and these substances are then excreted in the urine. The nurse identifies the presence of which substances in the urine as abnormal findings?
Glucose and protein
The nurse creating a nutritional care plan for a patient with Huntington's disease often focuses on the patient:
Having a need for increased calories
The nurse is caring for a patient experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?
Heart failure
A nursing instructor is talking with her clinical group about patients with acute glomerulonephritis. The instructor tells the students that the patient may exhibit which of the following clinical manifestations?
Hematuria
Which of the following nursing diagnoses is appropriate for a patient with amyotrophic lateral sclerosis (ALS)?
Impaired verbal communication
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
Loosen the patient's restrictive clothing.
Which nursing intervention takes highest priority for the nurse caring for an unconscious patient?
Maintaining a patent airway
A patient who experienced a thrombotic stroke and has residual hemiparesis of the right side is under-going rehabilitation. The nurse caring for this patient reinforces occupational therapy recommendations by placing items for personal hygiene:
On the over-bed table on the left side
Three weeks after being treated for strep throat, a patient comes into the clinic with signs of acute glomerulonephritis. Which symptom will the nurse most likely find upon assessment of this patient?
Periorbital edema
The patient tells the nurse that she has been taking phenytoin (Dilantin) for 2 years now and is still having too many side effects. She wants to stop taking it. What is the best response by the nurse?
Please do not stop the medication abruptly, as you will have withdrawal seizures, contact your health care provider
The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what proirity assessment data?
Potassium level
A patient diagnosed with TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done to do what?
Prevent a stroke by removing atherosclerotic plaques blocking cerebral flow
You are a critical care nurse admitting a patient in Myasthenic Crisis to the ICU. You know the most important aspect in the immediate management of this patient is what?
Providing ventilatory assistance
The nurse is giving discharge instructions to a patient diagnosed with pyelonephritis. Which statement by the patient would indicate that learning has occurred?
Pyelonephritis is an infection of the kidney.
The pathophysiology instructor is talking to the pre-nursing students about hypovolemia and the kidneys. The instructor points out that when the blood pressure is low due to dehydration with a decrease in renal perfusion the kidney will compensate by secreting what?
Renin
The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest?
Resting in an air-conditioned room whenever possible
The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). The nurse plans care based on which understanding of the patient's prognosis?
The disease progresses slowly and is fatal.
A patient is prescribed corticosteroid therapy. What would be priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy?
The patient is at an increased risk for developing infection.
The nurse caring for a patient who suffered an ischemic stroke resulting in disturbed sensory perception is aware that:
The patient should be approached on the side where visual perception is intact.
The patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family is adamant that she remains on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family?
The patient should mobilize as soon as she is physically able
A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patient's stools will have what characteristics?
Watery with blood and mucus
A patient with chronic obstructive pulmonary disease (COPD) tells the nurse that he does not always wear the prescribed oxygen at home because it is cumbersome and he is rarely short of breath. What is the nurse's best response to this patient?
Wearing the oxygen will help keep your blood oxygen saturation levels up so your heart does not have to work as hard and will not become enlarged.
A patient has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse implement following this procedure?
Wrap the joint in a compression dressing.
The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make?
You seem upset. I will sit down and we can talk for a while
A nurse is teaching a patient who has tuberculosis (TB). Which of the following statements should the nurse include in the teaching?
You will need to continue to take mutli-medication regimen for 6-12 months.
A nurse is assessing the skin of an older patient with dry skin and notices several areas of scratches and abrasion. Interventions should be implemented to meet what goal?
decrease the risk of infection
A group of nursing students are giving an oral report on multiple sclerosis (MS) to their med-surg class. What primary manifestation would the student report is the most likely to be assessed in a patient with MS?
difficulty in coordination
