MCA II- AQ #1

Which amount of time is the maximum amount the nurse would permit an older adult with a cerebrovascular accident (CVA) to remain in one position? A) 1 to 2 hours B) 3 to 4 hours C) 15 to 20 minutes D) 30 to 40 minutes

A) 1 to 2 hours

Which statement by a client who is seen for follow-up in the heart failure clinic is most important for the nurse to communicate to the health care provider? A) "I am unable to run 1 mile (1.6 km) now." B) "I wake up at night short of breath." C) "My spouse says I snores loudly." D) "My shoes seem larger lately."

B) "I wake up at night short of breath."

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet? A) Body weight control B) Decreased fluid retention C) lowering of blood pressure D) Prevention of hypernatremia

B) Decreased fluid retention

Which goal would the nurse include in the plan of care for a client who manifests right-sided hemianopsia as a result of a cerebrovascular accident (CVA)? A) Correct the client's misuse of equipment B) Instruct the client to scan the surroundings C) Teach the client to look at the position of the left extremities D) Provide the client with tactile stimulation to the affected extremities.

B) Instruct the client to scan the surroundings

Which instruction would the nurse include when teaching about hydrochlorothiazide given to a client diagnosed with a transient ischemic attack (TIA) related to hypertension? A) "Resume regular eating habits." B) "Drink a protein supplement daily." C) "Avoid eating foods high in insoluble fiber." D) "Increase the intake of potassium-rich foods."

D) "Increase the intake of potassium-rich foods."

Which intervention would the nurse implement after determining that a client, who sustained a cerebrovascular accident (CVA), needs assistance with eating for optimum nutrition? A) Request that a client's food be pureed. B) Feed the client to conserve the client's energy. C) Have a family member assist the client with each meal. D) Encourage the client to participate in the feeding process.

D) Encourage the client to participate in the feeding process.

Which medication prescribed for a client with an acute episode of heart failure would the nurse question? A) Diuretic B) Beta blocker C) Long-acting nitrate D) Angiotensin receptor blocker

B) Beta blocker

Which intervention related to post-cerebrovascular accident (CVA) urinary incontinence would the nurse include in the client's plan of care? A) Insert a urinary retention catheter B) Institute measures to prevent constipation C) Encourage an increased intake of caffeine D) Suggest daily ingestion of a carbonated beverage

B) Institute measures to prevent constipation

Which lobe of the brain would the nurse conclude is affected in a client unable to differentiate between heat or cold and sharp or dull sensory stimulation after a cerebrovascular accident (CVA)? A) Frontal B) Parietal C) Occipital D) Temporal

B) Parietal

Which assessment is the priority when a client with heart failure reports a 9-pound (4-kilogram) weight gain in the past 2 weeks? A) Palpate the abdomen B) Check for ankle edema C) Auscultate breath sounds D) Ask about dietary salt intake

C) Auscultate breath sounds

Which action would the nurse implement to prevent the development of plantar flexion when providing care for a client who sustained a cerebrovascular accident (CVA) 2 days ago? A) Place a pillow under the thighs B) Elevate the knee gatch of the bed C) Encourage an active range of motion D) Maintain the feet at right angles to the legs

D) Maintain the feet at right angles to the legs

Which clinical manifestation would the nurse expect to find when a client is admitted with right ventricular failure? A) Chest pain B) Bradypnea C) Bradycardia D) Peripheral edema

D) Peripheral edema

Which instruction regarding nutrition will the nurse give a client discharged after a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension who is on a regimen that includes chlorothiazide? A) "Eat more dark green, leafy vegetables such as spinach." B) "Substitute a potassium- based salt substitution for table salt." C) "Return to previous eating habits." D) "Increase intake of dairy products."

A) "Eat more dark green, leafy vegetables such as spinach."

Three days after admission to the hospital for a brain attack(cerebrovascular accident [CVA]), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action would the nurse take to evaluate whether the feeding is being absorbed? A) Aspirate for residual volume B) Evaluate the intake in relation to the output C) Instill air into the client's stomach while auscultating D) Compare the client's body weight with the baseline data

A) Aspirate for residual volume

The heartbeat assessment of four clients is given below. Which client isat an increased risk for right-sided heart failure? A) Client A Right Jugular Venous Pressure: 2.5 cm Left Jugular Venous Pressure: 3.0 cm B) Client B Right Jugular Venous Pressure: 2.0 cm Left Jugular Venous Pressure: 1.5 cm C) Client C Right Jugular Venous Pressure: 1.5 cm Left Jugular Venous Pressure: 1.0 cm D) Client D Right Jugular Venous Pressure: 3.0 cm Left Jugular Venous Pressure: 1.0 cm

A) Client A Right Jugular Venous Pressure: 2.5 cm Left Jugular Venous Pressure: 3.0 cm

When assessing a client with right ventricular heart failure, the nurse would expect which finding? Select all that apply. One, some, or all responses may be correct. A) Dependent edema B) Swollen hands and fingers C) Collapsed neck veins D) Right upper quadrant discomfort E) Oliguria

A) Dependent edema B) Swollen hands and fingers D) Right upper quadrant discomfort

Which action would the nurse take next when a client with a history of heart failure on daily weights has a 4-pound (1.8- kilogram) weight gain since the previous day? A) Perform a head-to-toe assessment B) Place the client on a restricted sodium diet with the client. C) Discuss a restricted sodium diet with the client. D) Document the findings in the health care record.

A) Perform a head-to-toe assessment

When a client with a heart murmur reports gaining weight in spite of nausea and anorexia, which additional information would be a priority for the nurse to obtain? A) Presence of a cough and exertional dyspnea B) Dietary food and salt intake in the past 24 hours C) Changes in voiding and bowel patterns within the past month D) History of childhood streptococcal infection or rheumatic fever

A) Presence of a cough and exertional dyspnea

Which rationale explains the importance of the nurse identifying mobility restrictions or neuromuscular abnormalities when assessing a client who experienced a recent cerebrovascular accident (CVA) and has a residual right-sided hemiplegia? A) Shortening and eventual atrophy of the affected muscles will occur B) Hypertrophy of the muscles eventually result from disuse C) Extension rigidity can occur, making therapy painful and difficult D) Decreased movement on the affected side predisposes the client to infection

A) Shortening and eventual atrophy of the affected muscles will occur

The nurse would instruct a client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) to monitor for which indication of right-sided heart failure upon discharge? A) Weight gain B) Hypertension C) Increased appetite D) Clubbing of the nail beds

A) Weight gain

Which client condition requires a medium priority of care according to the National Institutes of Health Stroke Scale (NIHSS) score? A) Visual score of 3 B) Facial palsy score of 1 C) Level of consciousness score of 0 D) Motor and drift of each extremity score of 4

B) Facial palsy score of 1

Which finding for a client who has a diagnosis of paroxysmal atrial fibrillation is most important to report quickly to the health care provider? A) Irregular heartbeat B) Right arm weakness C) Client report of palpitations D) Client report of lightheadedness

B) Right arm weakness

Which finding would the nurse expect when assessing a client who has right ventricular failure? A) Slowed pulse rate B) Pleural friction rub C) Neck vein distention D) Elevated temperature

C) Neck vein distention

Which assessment finding is a late sign of heart failure? A) Tachypnea B) Tachycardia C) Peripheral edema D) Periorbital edema

C) Peripheral edema

Which explanation would the nurse provide to a client about transient ischemic attacks (TIAs)? A) Temporary episodes of neurological dysfunction B) Intermittent attacks caused by multiple small clots C) ischemic attacks that result in progressive neurological deterioration D) Exacerbations of neurological dysfunction alternating with remissions

A) Temporary episodes of neurological dysfunction

Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct. A) Diuretics B) Low-salt diet C) Daily weight checks D) Fluid restriction E) Intake and output F) Oxygen administration

A) Diuretics B) Low-salt diet C) Daily weight checks D) Fluid restriction E) Intake and output F) Oxygen administration

Which parameter would the nurse assess in a client with right-sided heart failure? A) Fluid volume B) Lung sounds C) Mental status D) Respiratory rate E) Peripheral pulses

A) Fluid volume

Which information would the nurse include when explaining the cause of transient ischemic attacks (TIAs) to a client? A) Genetic valvular heart disease B) Atherosclerotic plaques within arteries C) Developmental defects in arterial walls D) Emboli ascending from the lower extremities

B) Atherosclerotic plaques within arteries

Which response by the nurse is best when the primary health care provider prescribes "bathroom privileges only" for a client with an exacerbation of heart failure and the client becomes irritable and asks why bed rest is needed? A) "Why do you want to be out of bed?" B) "Bed rest plays a role in most therapy." C) "Rest reduces the amount of work your heart has to do right now." D) "Maybe the primary health care provider will increase your activity tomorrow."

C) "Rest reduces the amount of work your heart has to do right now."

Which statement by a client is consistent with a diagnosis of heart failure? A) "I see spots before my eyes" B) " I am tired at the end of the day." C) "I feel bloated when I eat a large meal." D) "I have trouble breathing when I climb a flight of stairs"

D) "I have trouble breathing when I climb a flight of stairs"

Which statement by the client would the nurse expect when assessing a client with a diagnosis of left ventricular failure? A) "My ankles are swollen." B) "My appetite is not very good." C) "When I eat a large meal, I feel bloated." D) "I have trouble breathing when I walk rapidly."

D) "I have trouble breathing when I walk rapidly."

Which explanation would the nurse provide about the client's behavior when family members of a client who had a cerebrovascular accident(CVA) ask why the client cries easily and without provocation? A) Has little control over this behavior B) Is making an attempt to get attention C) Feels guilty about the demands being made on the family D) Has selective memory from the past, especially the sad events

A) Has little control over this behavior

Which lifestyle factor, that may have contributed to the ankle swelling,would a nurse ask about when questioning a client with heart failure and new onset ankle edema? Select all that apply. One, some, or all responses may be correct. A) Intake of salty foods B) Dietary fat intake C) Medication compliance D) Family stresses E) Recent travel

A) Intake of salty foods C) Medication compliance E) Recent travel

Which assessment finding indicates that a client has had a stroke? Select all that apply. One, some, or all responses may be correct. A) Lopsided smile B) Unilateral vision C) Incoherent speech D) Unable to raise right arm E) Symptoms started 2 hours ago

A) Lopsided smile B) Unilateral vision C) Incoherent speech D) Unable to raise right arm E) Symptoms started 2 hours ago

Which instruction would the nurse give an unlicensed assistive personnel (UAP) to perform while caring for a client prescribed aptopril? Select all that apply. One, some, or all responses may be correct. A) Obtain blood pressure B) Measure intake and output C) Weigh the client every morning D) Notify the nurse if the client has a dry cough E) Assist the client to change positions slowly

A) Obtain blood pressure B) Measure intake and output C) Weigh the client every morning D) Notify the nurse if the client has a dry cough E) Assist the client to change positions slowly

Which nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? A) Place objects within the visual field B) Teach passive range-of-motion exercises C) Instill artificial teardrops into the affected eye D) Reduce time client is positioned on the left side

A) Place objects within the visual field

Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring? Select all that apply. One, some, or all responses may be correct. A) Wearing a medical alert bracelet B) Initiating bleeding precautions C) Refraining from estrogen therapy D) Obtaining routine prothrombin times E) Notifying providers of anticoagulation

A) Wearing a medical alert bracelet B) Initiating bleeding precautions C) Refraining from estrogen therapy D) Obtaining routine prothrombin times E) Notifying providers of anticoagulation

Which nursing intervention is most important for supporting the success of the bowel training program for a client who sustained a cerebrovascular accident (CVA) and is incontinent of feces? A) Use prescribed medications to induce elimination B) Adhere to a definite time for attempted evacuations C) Consider previous habits associated with the clients defecation D) Time scheduled eliminations to take advantage of the gastrocolic reflex

B) Adhere to a definite time for attempted evacuations

For a client with a hemorrhagic stroke secondary to a motor bike accident, which client finding requires immediate attention? A) Glasgow Coma score of 10 B) Body temperature of 81.2 degrees Fahrenheit C) Oxygen (O2) saturation of 90% D) Presence of carotid pulse with blood pressure (BP) of 80 mm Hg

B) Body temperature of 81.2 degrees Fahrenheit

Which type of lung sounds would the nurse expect to hear when caring for a client with heart failure? A) Stridor B) Crackles C) Wheezes D) Rhonchi

B) Crackles

Which assessment finding is consistent with a client diagnosis of right-sided heart failure? Select all that apply. One, some, or all responses may be correct. A) Collapsed neck veins B) Distended abdomen C) Dependent edema D) Decreased appetite E) Cool extremities

B) Distended abdomen C) Dependent edema D) Decreased appetite

Which findings would the nurse expect when caring for a client with cor pulmonale? Select all that apply. One, some, or all responses may be correct. A) Weight loss B) Neck vein distension C) Lower extremity edema D) Right upper quadrant abdominal tenderness E) Lower than normal hemoglobin and hematocrit F) Elevated B-type natriuretic peptide (BNP) levels

B) Neck vein distension C) Lower extremity edema D) Right upper quadrant abdominal tenderness F) Elevated B-type natriuretic peptide (BNP) levels

How would the nurse describe heart failure to a client? A) A cardiac condition caused by inadequate circulating blood volume B) An acute state in which the pulmonary circulation pressure decreases C) An inability of the heart to pump blood in proportion to metabolic needs D) A chronic state in which the systolic blood pressure drops below 90 mm Hg

C) An inability of the heart to pump blood in proportion to metabolic needs

A client who recently experienced a brain attack (cerebrovascular accident [CVA]) and has limited mobility reports constipation. Which is most important for the nurse to determine when collecting information about the constipation? A) Presence of distention B) Amount of high-fiber food consumed C) Length of time this problem has existed D) Extent of discomfort when attempting to defecate

C) Length of time this problem has existed

Which information would the nurse include in the discharge teaching plan for a client who sustained a cerebrovascular accident (CVA) with residual hemiparesis and hemianopsia? A) Necessity for bed rest at home B) Use of oxygen (O2) therapy at home C) Significance of a safe environment D) Need for decreased protein in the diet

C) Significance of a safe environment

Which behavior would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain? Select all that apply. One, some, or all responses may be correct. A) Impaired judgement B) Spatial-perceptual deficits C) Slow performance and caution D) Impaired speech/ language aphasias E) Tendency to deny or minimize problems F) Awareness of deficits with depression and anxiety

C) Slow performance and caution D) Impaired speech/ language aphasia F) Awareness of deficits with depression and anxiety

When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report? A) Losing weight over the past week B) Tingling in the upper extremities C) Using several pillows at night to sleep D) Wheezing when exposed to dust or pollen

C) Using several pillows at night to sleep

A 50-year-old client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA). When the nurse inquired about the client's feelings, the spouse responded. Which communication strategy would the nurse use to address this behavior? A) Ask the spouse how they know the client's feelings. B) Insturct the spouse to let the client answer C) When the spouse leaves, return to speak with the client D) Acknowledge the spouse, but look at the client for a response

D) Acknowledge the spouse, but look at the client for a response

Which early sign of heart failure would the nurse recognize in an infant who has a congenital heart defect with left-to-right shunting of blood? A) Cyanosis B) Restlessness C) Decreased heart rate D) Increased respiratory rate

D) Increased respiratory rate

Which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident (CVA)? A) Glaucoma B) Hypothyroidism C) Continuous nervousness, stress D) Transient ischemic attacks (TIAs)

D) Transient ischemic attacks (TIAs)