HEHI FINAL Fall 2020 Review Questions
A client is admitted to the hospital with a tentative diagnosis of Guillian Barre syndrome. Which question by the nurse will elicit information consistent with this diagnosis? a- have you experienced an infection recently? b- is there a history of this disorder in your family? c- did you receive a head injury during the past year? d- what medications have you taken in the past several months?
A
A client asks the nurse what causes the sudden loss of vision common in persons with MS. What factor would the nurse include in the explanation? a- virus- induced iritis b- intracranial pressure c- close angled glaucoma d- optic nerve inflammation
D
A patient presents with tracheal deviation to the left side. The nurse knows this is a sign of what underlying disorder? a- obstructive sleep apnea b- left ventricular hypertrophy due to valve stenosis c- tension pneumothorax of the right lung d- empyema secondary to pneumonia
C
A client experienced a tonic-clonic seizure. Which nursing intervention is the priority during the tonic-clonic stage of the seizure? a- go for additional help b- establish a patent airway c- turn the patient on their side d- protect the patient from injury
D
A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? a- dull sound on percussion b- vocal fremitus on palpation c- rales with rhonchi on auscultation d- absence of breath sounds on auscultation
D
The nurse notes a patient who sustained a large stroke has profound mobility deficits and is unable to turn on their own. On assessment of the patient's sacral area, a red area blanches with palpation. What is this? a- stage I pressure injury b- stage II pressure injury c- venous stasis ulcer d- a warning sign of impending pressure injury
D
The nurse suspects increased ICP in a patient as evidence by Cushing's triad. Which of the following best describes the respiratory pattern in Cushing's Triad? a- persistent apnea unless the nurse performs a sternal rub b- periods of alternating hyperventilation and apnea c- kussmaul's respirations d- tachypnea with shallow respirations
B
A patient is undergoing the tensilon test. The nurse knows this helps diagnose what condition?
myasthenia gravis
A patient has undergone placement of a mechanical valve. A mechanical heart valve increases the risk of what kind of stroke? a- embolic stroke b- thrombotic stroke c- hemorrhagic stroke d- watershed stroke
A
A patient with severe carotid artery stenosis is about to undergo endarterectomy. Which of the following findings should be reported to the team immediately? a- platelet count of 60,000 b- hemoglobin of 14g/dL c- temperature of 98.9 d- carotid bruit auscultated on assessment
A
The nurse notices the family of a patient with severe post-stroke dysphagia giving the patient soda, though the patient has orders for thickened liquids. What is the greatest risk to the patient? a- aspiration pneumonia b- acidosis due to carbonation c- hyperglycemia d- dyspepsia due to altered stomach motility
A
While in the playroom, a school-aged child exhibits twitching of the right arm and leg that almost immediately progresses to generalized tonic-clonic seizures with clenched jaws. Which action would the nurse take after moving the child to the floor? a- moving objects away from the child b- taking the other children to other rooms c- inserting a plastic airway into the child's mouth d- positioning a large pillow under the child's head
A
Which findings would the nurse expect when completing an admission physical for a client with diagnosis of Parkinson disease? SATA a- muscle rigidity b- blank facial expression c- leaning toward the affected side d- intention tremors with movement e- hyperextension of the affected extremity
A B
Which assessment finding indicates that a client has had a stroke? a- lopsided smile b- unilateral vision c- incoherent speech d- unable to raise right arm e- symptoms started 2 hours ago
A B C D
The nurse is preparing a patient with a stroke for fibrinolytic therapy. Which of the following would be a contraindication? SATA: a- allergy to TPA b- car accident with head bleed two months ago c- history of gall bladder removal 8 years ago d- patient is on beta blockers for HTN e- history of arteriovenous malformation
A B E
which clinical indicators would the nurse consider evidence of increase ICP? SATA a- vomiting b- irritability c- hypotension d- increased respirations e- decreased level of consciousness
A B E
A child with a seizure disorder has a generalized seizure shortly after admission to the hospital. Which nursing actions are most appropriate? SATA: a- assessing the time of the seizure b- taking the child's vital signs c- turning the child on the side d- pulling the padded side rails up e- initiating O2 therapy
A C D
The nurse is caring for a patient at high risk of pulmonary embolism due to venous insufficiency. Which of the following would be a sign of large pulmonary embolism? a- new wheezes on auscultation b- hypotension due to decreased left ventricular filling c- productive cough with purulent sputum d- absent breath sounds in the left lower lobe
B
The nurse is preparing a patient for lumbar puncture as a part of seizure workup. The patient asks what the purpose of a lumbar puncture is: a- the lumbar puncture can tell us which neurotransmitters are out of alignment b- the lumbar puncture will help us rule out meningitis c- the lumbar puncture will allow us to add fluid to your CSF, which will reduce your seizure threshold d- the lumbar puncture will help us determine your electrolyte levels
B
The nurse notices the family of a patient with severe post-stroke dysphagia giving the patient soda, though the patient has orders for thickened liquids. What is the best response? a- sternly condemn the family for endangering the patient's health b- ask the family about their understanding of the patient's dietary modification c- inform the family that only nursing staff my feed the patient d- teach the family how to administer soda via PEG tube
B
What is the function of the water seal chamber on a closed chest drainage system for a client with hemothorax? a- collects drainage from the pleural space b- prevents reflux of air back into pleural space c- promotes drainage of blood from the pleural space d- controls level of suction applied to intrapleural space
B
Which clinical finding would the nurse expect to identify for a client with a new diagnosis of myasthenia gravis? a- tearing b- diplopia c- nystagmus d- exophthalmos
B
A client who had a CVA begins to eat lunch. Which client behavior indicates the client may be experiencing left hemianopsia? a- the client asks to have food moved to the left side of the tray b- the client drops the coffee cup when trying to use the right hand c- the client ignored the food on the left side of the tray when eating d- the client reports not being able to use the right arm to help eat meals
C
A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with spontaneous pneumothorax. The client asks, "how could this have happened?" The nurse's response is based on which likely cause of the spontaneous pneumothorax? a- pleural friction rub b- tracheoesophageal fistula c- rupture of a subpleural bleb d- puncture wound of the chest wall
C
The RN notices reddish linear streaks in the nail bed of the client. Which systemic condition would the RN suspect in the client based on these assessment findings? a- syphilis b- iron-deficiency anemia c- bacterial endocarditis d- COPD
C
The nurse notes splinter hemorrhage's and Janeway lesions on a patient's hands and feet. Which type of stroke is the patient at greatest risk for? a- thrombotic b- rupture of AVM c- embolic stroke d- subdural hemorrhage
C
When assessing a client, the nurse auscultates a murmur at the second intercostal space along the sternal border. Which valve does this sound reflect? a- aortic b- mitral c- pulmonic d- tricuspid
C
Which characteristic would a client who has been taught about myasthenia gravis identify as being common to both myasthenic and cholinergic crises? a- diarrhea b- salivation c- difficulty breathing d- abdominal cramping
C
Which complication would the nurse assess in both clients who have Parkinson and myasthenia gravis? a- cogwheel gait b- impaired cognition c- difficulty swallowing d- nonintention tremors
C
Which topic would be included in discharge teaching for a 22 year old client who has mitral valve replacement with a mechanical valve? a- daily aspirin use b- care of leg incisions c- anticoagulation therapy d- low fat and cholesterol diet
C
which finding would the nurse expect when assessing a client admitted for elective endovascular repair of a large aortic aneurysm? a- severe radiating abdominal pain b- pattern of visible peristaltic waves c- visible pulsating abdominal mass d- bilateral ankle swelling and redness
C
When the nurse is caring for a client on the first postoperative day after a lobectomy, which assessment finding requires the most rapid action by the nurse? a- oxygen saturation 93% b- client has poor cough effort c- incision edges are red and swollen d- trachea deviates to the nonsurgical side
D
Which response would the nurse offer when a client undergoing brachytherapy for breast cancer asks what precautions need to be observed? a- there are no restrictions during brachytherapy b- all body fluid during therapy is treated as radioactive c- you should maintain contact isolation during your treatment d- visitors should be limited, particularly pregnant women and children
D
