Med Surg 2 study guide

When communicating with a client who has aphasia, which approaches are helpful? (select all that apply) A. Make use of gestures B. Present one thought at a time C. Avoid writing messages D. Speak with normal volume E. Encourage pointing to the needed object

A, B, D, E

a 21-year-old female client takes clonazepam. What should the nurse ask about this client? (select all that apply) A seizure activity B pregnancy status C Alcohol use D cigarette smoke E intake of caffeine

A,B,C,D,E

Cerebral arteries are more prone to rupture during hypertension because: A there are so many of them B they have autoregulation C they are thin and delicate D they are not protected by skeletal muscles

C they are thin and delicate

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring, The nurse should monitor the client for which of the following complications related to the ventriculostomy? A headache B aphasia C infection D HTN

Infection

The health care provider determines she had increased intracranial pressure because of the new confusion levels. Which of the following ICP monitoring systems would the health care provider place that is most accurate and reliable, and allows for drainage of CSF? Subarachnoid bold intraventricular catheters Epidural catheters Intraparenchymal catheters

Intraventicular cath

A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patient's left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes? Parietal Temporal Occipital Frontal

Occipital

What layer of the brain is CSF in?

The space between the arachnoid and the pia mater, the subarachnoid space, contains CSF

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? Unequal pupil size Decreasing systolic blood pressure Decreasing body temperature tachycardia

Unequal pupil size

a client is at risk for increased ICP. which finding is the priority for the nurse to monitor? A unequal pupil size B decreasing systolic BP C tachycardia D decreasing body temp

unequal pupil size

a nurse is providing discharge instructions on phenytoin to a female client with tonic-clonic seizure disorder. Which instructions should the nurse include? (select all that apply) A receive necessary periodic bloodwork B report any problems with walking or coordination, slurred speech, or nausea C maintain adequate amounts of fluid and fiber in the body D monitor the body for any skin rash E perform good oral hygiene

A, B, D, E

Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? (Select all that apply) A the ability to select medications for the neurologic dysfunction B understanding the tests used to diagnose neurologic disorders C knowledge of nursing interventions related to assessment and diagnostic testing D knowledge of anatomy of the nervous system E ability to interpret the results of diagnostic tests

B, C, D

the client will have an EEG in the morning. The nurse should instruct the client to have which foods/fluids for breakfast? A no foods or fluids B only coffee or tea C full breakfast as desired without coffee, tea, or energy drinks D a liquid breakfast of fruit juice, oatmeal, smoothie

C

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following? b. "Have you experienced any ptosis in the last few weeks?" d. "Have you developed any new allergies in the last year?" a. "Have you experienced any viral infections in the last month?" c. "Have you had difficulty with urination in the last 6 weeks?"

a. "Have you experienced any viral infections in the last month?"

When the nurse performs oral hygiene for an unconscious client, which nursing intervention is the priority? A keep suction machine available B place pt in a prone position C Wear sterile gloves while brushing the pts teeth D Use gauze wrapped around the fingers to clean the client's gums

keep suction machine available

a patient is scheduled for a CT scanning of the head because of a recent onset of neurological deficits. What should the nurse tell the patient in preparation for this test? A no metal objects can enter the procedure room B you need to fast for 8 hrs prior to the test C you will need to lie still throughout the procedure D there will be a lot of noise during this test

you will need to lie still during this test

what is the priority nursing intervention in the post-ictal phase of a seizure? A reorient the client to person, place, time B Determine the client's level of sleepiness C assess the clients breathing pattern D position the pt comfortably

assess the client's breathing pattern

The nurse is teaching a client about taking prophylactic warfarin sodium. Which statement indicates that the client understands how to take the drug? Select all that apply. "I should have my blood levels tested periodically" "Protamine sulfate is the antidote for warfarin" Effects of the drug continue for 4 to 5 days after discontinuing the medication" "Maximum dosage is not achieved until 3 to 4 days after starting the medication" "the drug's action peaks in 2 hours

"I should have my blood levels tested periodically" "Effects of the drug continue for 4 to 5 days after discontinuing the medication" "Maximum dosage is not achieved until 3 to 4 days after starting the medication"

Penny Williams, a 74-year-old patient, is admitted to the telemetry unit with the diagnosis of acute ischemic stroke. The patient is experiencing paroxysmal atrial fibrillation with a controlled ventricular rate on the monitor. A CT of the head without contrast reveals no evidence of hemorrhage. The transesophageal echocardiogram reveals moderate mitral valve insufficiency and embolism as a primary cause of the stroke. The patient is on a weight-based heparin protocol. The patient received digitalis to keep the ventricular rate of the atrial fibrillation controlled. The patient has right-sided paralysis and global aphasia. The patient has unilateral neglect of her right side and has right field homonymous hemianopsia. Papilla edema is present bilaterally. The patient is drooling from the right side of her mouth and coughs periodically. The patient was found by her daughter when she got home from work. The daughter stated her mother was normal before she left for work, and 10 hours later the mother exhibited the symptoms described above. The time of onset for the stroke could not be safely determined so no interventions could be used to treat the stroke. The physician orders Heparin bolus of 10,000 Units, followed by an IV drip of 18 Units/kg/hr. Your patient weighs 167 lbs. 76 kg. Pharmacy sends you: Heparin bolus concentration; 5,000 Units/mL and Heparin IV drip concentration 50,000 Units/1000 1. What is your initial bolus dose? 2. What is your IV drip Units/hr rate?

1. 2mL/hr, 2. 1368 units/hr 1. 2 and 2. 1368 1. 2ml, 2. 1368units

The healthcare provider orders an IV dose of Mannitol. 1.5g/kg. pt weighs 180lbs. Pharmacy sends you 15g/100mL. How many mL's of this solution would you administer

818

What is the priority nursing intervention in the postictal phase of a seizure? Position the client comfortably Determine the client's level of sleepiness Reorient the client to time, person, and place Assess the client's breathing pattern

Assess the client's breathing pattern

A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patient's health problem? A lesion in the pons Cerebellar dysfunction A hemorrhage in the midbrain Dysfunction of the medulla

Cerebellar dysfunction

A nurse is caring for client who sustained a head injury and has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? Hyponatremia Hyperglycemia Hypervolemia Oliguria

Hyponatremia

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first? A Contact the healthcare provider (HCP) and request a prescription for soft wrist restraints B Ask the family to stay with the client C Increase the frequency of client observation D Administer a sedative at bedtime

Increase the frequency of client observation

When the nurse performs oral hygiene for an unconscious client, which nursing intervention is the priority? Wear sterile gloves while brushing the client's teeth Place the client in a prone position Wear sterile gloves while brushing the client's teeth Keep a suction machine available

Keep a suction machine available

The nurse is discharging a client home after surgery for trigeminal neuralgia. What advice should the nurse provide to this client in order to reduce the risk of injury? c. Avoid rubbing the eye on the affected side of the face b. Use over-the-counter antibiotic eye drops for at least 14 days d. Rinse the eye on the affected side with normal saline for 1 week a. Avoid watching television or using a computer for more than 1 hour at a time

c. Avoid rubbing the eye on the affected side of the face

A client, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? a. Metastasis d. Pathologic bone fractures b. Risk for stroke c. Emotional and personality changes

c. Emotional and personality changes

Which term is used to describe edema of the optic nerve? a. Scotoma c. Papilledema b. Lymphedema d. Angioneurotic edema

c. Papilledema

A client with Parkinson disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method? d. Minced foods and a fluid restriction b. Provision of a low-residue diet a. Total parenteral nutrition (TPN) c. Semisolid food with thick liquids

c. Semisolid food with thick liquids

One day after cataract surgery, the client is having discomfort from bright light. The nurse should advise the client to: d. Patch the affected eye when in bright light c. Use sunglasses that wrap around the side of the face when in bright light a. Dim lights in the house and stay inside for 1 week b. Attach sun shields to existing eyeglasses when in direct sunlight

c. Use sunglasses that wrap around the side of the face when in bright light

A patient with an uncoordinated gait has presented to the clinic. Which of the following is the most plausible cause of this patient's health problem? A cerebellar dysfunction B lesion in the pons C dysfunction in the medulla D hemorrhage in the midbrain

cerebellar dysfunction

The nurse is assessing a client in the post-ictal phase of a generalized tonic-clonic seizure. The nurse should determine if the client has which symptom following the seizure? A inability to move B drowsiness C paraesthesia D hypotension

drowsiness

Which of the following ICP monitoring systems would the healthcare provider place that is the most accurate and reliable, and allows for drainage of CSF? A intraventicular catheters B intraparenchymal catheters C subaracnoid bolt D epidural catheters

intraventricular cath

GCS is useful because: A it is standardized B evaluates the ability to interpret stimuli C is subjective D evaluates vital signs and pupil reactivity

it is standardized

What finding indicates that performing passive range-of motion (ROM) exercises on an unconscious client has been successful? maintenance of joint mobility increase in muscle tone preservation of muscle mass prevention of bone demineralization

maintenance of joint mobility

A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patient's left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes? A temporal B occipital C parietal D frontal

occipital

a nurse is assessing a client's extra ocular eye movements as part of evaluating neurological functioning. This documents the status of which cranial nerves? (Select all that apply) A oculomotor (III) B acoustic (VIII) C Abducens (VI) D optic (II) E trigeminal (V) F Trochlear (IV)

oculomotor, abducens, trochlear

what term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? A dura mater b arachnoid c fascia d pia mater

pia mater

An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patient's family that it is essential that the patient have what installed in the home? A grab bars B non slip mats C baseboard heaters D smoke detectors

smoke detectors

A nurse is developing a plan of care for a client who is scheduled for a cerebral angiogram with contrast dye. Which of the following statements by the clients family member should the nurse report to the provider? (select all that apply) A I think she might be pregnant B she takes Coumadin C she takes antihypertensive medication D she is allergic to shrimp E she is allergic to latex

A, B, D

The unconscious client is to receive 200mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40mL if gastric residual. The nurse should: A. Withhold the tube feeding and notify the healthcare provider (HCP) B. Delay feeding the client for 1 hour and then recheck the residual C. Dispose of other residual and continue with the feeding D. Re-administer the residual to the client and continue with the feeding

D. Re-administer the residual to the client and continue with the feeding

a nurse is providing teaching to the partner of an older adult who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective? A this medication should help my husband's daily function B this medication should help my husband sleep better C this medication should increase my husband's appetite D this medication should increase my husbands energy level

This medication should help my husband's daily function

An older adult has encouraged her husband to visit their primary provider, stating that she is concerned that he may have Parkinson disease. Which of the wife's descriptions of her husband's health and function is most suggestive of Parkinson disease? b. "He often complains that his joints are terribly stiff when he wakes up in the morning." d. "He's losing weight even though he has a ravenous appetite." a. "Lately he seems to move far more slowly than he ever has in the past." c. "He's forgotten the names of some people that we've known for years."

a. "Lately he seems to move far more slowly than he ever has in the past."

A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse? c. Discontinue the bath and resume it later. a. Accept the patient's behavior and do not take it personally b. Request that the patient be cared for by another nurse. d. Explain that the client is getting good care.

a. Accept the patient's behavior and do not take it personally

The nurse should assess an older adult with macular degeneration for: b. Loss of peripheral vision d. Blurring vision a. Loss of central vision c. Total blindness

a. Loss of central vision

The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? d. MS is sometimes caused by a bacterial infection a. MS is a progressive demyelinating disease of the nervous system b. MS usually occurs more frequently in men c. MS typically has an acute onset

a. MS is a progressive demyelinating disease of the nervous system

A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the client best make known his wishes for care as his disease progresses? a. Prepare an advance directive c. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association d. Ensure that witnesses are present when he provides instruction b. Designate a most responsible health care provider (MRP) early in the course of the disease

a. Prepare an advance directive

The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? d. Assessing frequently for loss of cognitive function c. Providing aids to compensate for loss of vision a. Using the incentive spirometer as prescribed b. Maintaining the client on bed rest

a. Using the incentive spirometer as prescribed

What should the nurse instruct a client who has cerumen buildup in the ear to do? (Select all that apply) e. Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution d. Use small forceps to extract the wax a. Wash the external ear with a washcloth b. Instill cerumenolytic drops in the ear canal c. Use cotton-tipped applicators to remove the wax from the ear canal

a. Wash the external ear with a washcloth b. Instill cerumenolytic drops in the ear canal e. Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution

GCS assesses? A cranial nerves b arousal C abstract thinking D awareness

arousal

The nurse identifies a nursing diagnosis of self-care deficit, bathing related to motor impairment and decreased cognitive function for a client with cerebral metastasis. Which outcome would the nurse most likely identify on this client's plan of care? b. Client participates in daily hygiene activities with assistive devices a. Client demonstrates positive coping strategies c. Client expresses feelings related to self-care ability d. Client consumes adequate calories to meet energy needs

b. Client participates in daily hygiene activities with assistive devices

A 25-year-old female client with brain metastases is considering her life expectancy after her most recent meeting with her oncologist. Based on the fact that the client is not receiving treatment for her brain metastases, what is the nurse's most appropriate action? c. Ensuring that the family does not tell the client that her condition is terminal b. Ensuring that the client receives adequate palliative care a. Promoting the client's functional status and ADLs d. Promoting adherence to the prescribed medication regimen

b. Ensuring that the client receives adequate palliative care

Which is the most common cause of acute encephalitis in the United States? c. Lyme Disease d. Human immunodeficiency virus (HIV) b. Herpes simplex virus a. Western equine bacteria

b. Herpes simplex virus

The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? d. Avoiding naps during the day c. Increasing the dose of muscle relaxants b. Resting in an air-conditioned room whenever possible a. Taking a hot bath at least once daily

b. Resting in an air-conditioned room whenever possible

A client is admitted to the emergency department with a headache, weakness, and slight confusion. The healthcare provider (HCP) diagnoses carbon monoxide poisoning. What should the nurse do first? c. Administer 100% oxygen by mask d. Obtain a psychiatric referral b. Maintain body temperature a. Initiate gastric lavage

c. Administer 100% oxygen by mask

The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective in assuring that the client understands the information? d. Show the client a DVD with instructions b. Provide instructions to the spouse, and have the spouse explain them to the client c. Give the client written material to read, and follow up with time for question a. Stand in front of the client, and slowly explain the instructions

c. Give the client written material to read, and follow up with time for question

A family member of a client diagnosed with Huntington disease calls you at the clinic. She is requesting help from the Huntington's Disease Society of America. What kind of help can this client and family receive from this organization? (Select all that apply.) c. Public education b. Referrals a. Information about this disease e. Appraisals of research studies d. Individual assessments

c. Public education b. Referrals a. Information about this disease

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? b. Related to difficulty swallowing a. Related to visual field deficits d. Related to psychomotor seizures c. Related to impaired balance

c. Related to impaired balance

a patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? A constricted pupils B dilated bronchioles C decreased peristaltic movement D relaxed muscular walls of the urinary bladder

constricted pupils

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure? A deep breathing B turning C coughing D passive ROM

coughing

A client who was diagnosed with Parkinson's disease several months ago recently began treatment with levodopa-carbidopa. The client and his family are excited that he has experienced significant symptom relief. The nurse should be aware of what implication of the client's medication regimen? a. The client is in a "honeymoon period" when adverse effects of levodopa-carbidopa are not yet evident. d. Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment. b. Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation of treatment. c. The client's temporary improvement in status is likely unrelated to levodopa-carbidopa.

d. Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the clients' cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action? c. Reposition the client to prevent further hemorrhage. d. Inform the surgeon of the possibility of a dural leak. b. Reinforce the dressing and reassess in 1 to 2 hours. a. Page the health care provider and report this sign of infection.

d. Inform the surgeon of the possibility of a dural leak.

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. urine output systolic blood pressure level of pain cerebral perfusion pressure breath sounds

systolic BP, Cerebral perfusion pressure