Med surge Exam 2
A CT scan of a 68-yr-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A Maintenance of the patient's airway B Positioning to promote cerebral perfusion C Control of fluid and electrolyte imbalances D Administration of tissue plasminogen activator (tPA)
A
A 54-yr-old patient with acute osteomyelitis asks the nurse how this problem will be treated initially. Which response by the nurse is most appropriate? A. "IV antibiotics are usually required for several weeks." B. "Oral antibiotics are often required for several months." C. "Surgery is almost always necessary to remove the dead tissue that present." D. "Drainage of the foot and instillation of antibiotics into the affected area are the usual
A
A 19-yr-old male patient has a plaster cast applied to the right arm for a Colles' fracture after a skateboarding accident. Which nursing action is most appropriate? A Elevate the right arm on two pillows for 24 hours. B Apply heating pad to reduce muscle spasms and pain. C Limit movement of the thumb and fingers on the right hand. D Place arm in a sling to prevent movement of the right shoulder.
A
signs of stroke
Face drooping, Arm weakness, Speech difficulty, time to call 9-1-1
A patient arrives to the ED with symptoms of a stroke. What is the first diagnostic test the nurse will expect to be ordered?
Non contrast Head CT
Injures to the right side can cause what deficits
impairments in attention, left neglect, memory issues, decreased awareness of deficits, loss of "big picture" thinking, altered creative or music perception
Right sided CVA S/S
paralyzed left side hemiplegia, spatial -perceptual deficits, tends to minimize problems, short attention span, visual field deficits, impaired judgement, impulsive, impaired time concept
Left sided CVA S/S
paralyzed right side hemiplegia, impaired speech and language, slow performance, visual field deficits, aware of deficits (depression, anxiety), impaired comprehension
Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? A Hypertension B Hyperlipidemia C Alcohol consumption D Oral contraceptive use
A
A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for A Surgical endarterectomy. B Transluminal angioplasty. C Intravenous heparin administration. D Tissue plasminogen activator (tPA) infusion.
D
A patient is receiving gentamicin (Garamycin) 80 mg IV twice daily for acute osteomyelitis. Which action should the nurse take before administering the gentamicin? A Ask the patient about any nausea. B Obtain the patients oral temperature. C Change the prescribed wet-to-dry dressing. D Review the patients blood urea nitrogen (BUN) and creatinine levels.
D
Injures of left side can cause what deficits
Difficulty understanding spoken and written language, difficulty expressing spoken and written language, changes in speech, verbal memory issues, impaired logic, sequencing difficulties
The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission? A Recent knee trauma B Debilitating joint pain C Repeated knee infections D Onset of frozen knee joint
B
The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. When completing a focused assessment, which symptom will the nurse expect? A. Nausea and vomiting B. Localized pain and warmth C. Paresthesia in the affected extremity D. Generalized bone pain throughout the leg
B
The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A Impulsivity B Impaired speech C Left-side neglect D Short attention span
B
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A Cholesterol level B Pupil size and pupillary response C Bowel sounds D Echocardiogram
B
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? A Apply an eye patch to the right eye B Place objects needed on the patient's left side C Place objects needed on the patient's right side D Teach the patient that the left visual deficit will resolve
B
When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/LVN? A Screen patient for tPA eligibility. B Assess the patient's ability to swallow. C Administer scheduled anticoagulant medications. D Place equipment needed for seizure precautions in room.
C
The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate? A TIA B Embolic stroke C Thrombotic stroke Incorrect D Subarachnoid hemorrhage
D
The nurse instructs the client with a right BKA to lie on the stomach for at least30 minutes a day. The client asks the nurse, "Why do I need to lie on my stomach? "Which statement is the most appropriate statement by the nurse? A "This position will help your lungs expand better." B "Lying on your stomach will help prevent contractures." C "Many times this will help decrease pain in the limb." D "The position will take pressure off your backside."
B
An assessment finding that alerts the nurse to the presence of osteoporosis in a middle-aged patient is A measurable loss of height. B the presence of bowed legs. C an aversion to dairy products. D statements about frequent falls.
A
The nurse is caring for a 76-yr-old man who has undergone left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively? A Progressive leg exercises to obtain 90-degree flexion B Early ambulation with full weight bearing on the left leg C Bed rest for 3 days with the left leg immobilized in extension D Immobilization of the left knee in 30-degree flexion to prevent dislocation
A
The patient has frostbite on the distal toes of both feet. The patient is scheduled for amputation of damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability? A Arteriogram showing blood vessels B Peripheral pulse palpation bilaterally C Patches of black, indurated, cold tissue D Bilateral pale, cool skin below the ankles
A
The patient with diabetes mellitus 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
Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? A Hypertension B Hyperlipidemia C Alcohol consumption D Oral contraceptive use
A
The nurse is caring for a client with a right below-the-knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implement first? A Notify the client's surgeon immediately. B Assess the client's blood pressure and pulse. C Reinforce the dressing with additional dressing D Check the client's last hemoglobin and hematocrit level.
B
The female client diagnosed with osteoporosis tells the nurse she is going to perform swim aerobics for 30 minutes every day. Which response is most appropriate by the nurse? A Praise the client for committing to do this activity B Explain to the client walking 30 minutes a day is a better activity. C Encourage the client to swim every other day instead of daily D Discuss with the client how sedentary activities help prevent osteoporosis.
B
A nurse performs discharge teaching for a 58-yr-old woman after a left hip arthroplasty using the posterior approach. Which statement by the patient indicates teaching is successful? A "Leg-raising exercises are necessary for several months." B "I should not try to drive a motor vehicle for 2 to 3 weeks." C "I will not have any restrictions now on hip and leg movements." D "Blood tests will be done weekly while taking enoxaparin (Lovenox)."
A
A patient is hospitalized for initiation of regional antibiotic irrigation for acute osteomyelitis of the right femur. Which intervention will be included in the plan of care? A Immobilization of the right leg B Frequent weight-bearing exercise C Avoiding administration of nonsteroidal anti-inflammatory drugs (NSAIDs) D Support of the right leg in a flexed position
A
A patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures complains of constant severe pain in the leg, which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? A Notify the health care provider. B Assess the incision for redness. C Reposition the left leg on pillows. D Check the patients blood pressure.
A
A patient with lower leg fracture has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching? A You will need to assess and clean the pin insertion sites daily. B The external fixator can be removed during the bath or shower. C You will need to remain on bed rest until bone healing is complete. D Prophylactic antibiotics are used until the external fixator is removed.
A
The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? A. Keep a wrench close or attached to the vest. B. Use the frame and vest to assist in positioning. C. Clean around the pins using betadine swab sticks. D. Loosen both sides of the vest to provide skin care.
A Rationale: A halo vest is used to provide cervical spine immobilization while vertebrae heal. A wrench should accompany the halo vest at all times in case emergency removal of the vest is needed (e.g., performance of CPR). Cleaning around the pins is typically performed with half strength hydrogen peroxide, normal saline, or chlorhexidine, based on provider instructions. Only one side of the vest can be loosened for skin care and changing clothes. After that side has been reattached, the other side of the vest can be loosened
The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which patient statement indicates teaching about autonomic dysreflexia is successful? A. "I will perform self-catheterization at least six times per day." B. "A reflex erection may cause an unsafe drop in blood pressure." C. "If I develop a severe headache, I will lie down for 15 to 20 minutes." D. "I can avoid this problem by taking medications to prevent leg spasms."
A Rationale: Autonomic dysreflexia usually is caused by a distended bladder. Performing self-catheterization five or six times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache, hypertension, bradycardia, flushing, piloerection (goosebumps), and nasal congestion. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.
Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible autonomic dysreflexia? A. Headache and rising blood pressure B. Irregular respirations and shortness of breath C. Decreased level of consciousness or hallucinations D. Abdominal distention and absence of bowel sounds
A Rationale: Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory changes, decreased level of consciousness, and gastrointestinal complaints are not characteristic manifestations.
Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses
A Rationale: Neurogenic shock is caused by the loss of vasomotor tone after injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.
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,B,D,E
The nurse is teaching the family of a client with difficulty swallowing about decreasing the risk of aspiration while eating. Which of the following strategies should the nurse include in the teaching plan. (Select all that apply) A Maintaining an upright position while eating B Restricting the diet to liquids until swallowing improves C Introducing foods on the unaffected side of the mouth D Keeping distractions to a minimum E Cutting food into large pieces of finger food
A,C,D
When communicating with a client who has aphasia, which of the following are helpful? Select all that apply. A Present one thought at a time B Avoid writing messages C Speak with normal volume D Make use of gestures E Encourage pointing to the needed object.
A,C,D,E
The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? A 2 × 6 cm right calf abrasion with sanguineous drainage B Left leg externally rotated and shorter than the right leg C Stooped posture with a shuffling gait and slow movements D Mild pain and minimal swelling of the right ankle and foot
B
A female 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 the majority of the time. B Alternate the patient's positioning between supine and side-lying. C Avoid the use of pillows in order to promote independence in positioning. D Establish a schedule for the massage of areas where skin breakdown emerges.
B
A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left leg. Which information will be included in the discharge teaching? A How to apply warm packs safely to the leg to reduce pain B How to monitor and care for the long-term IV catheter site C The need for daily aerobic exercise to help maintain muscle strength D The reason for taking oral antibiotics for 7 to 10 days after discharge
B
During a health screening event, which assessment finding in a white, 61-yr-old woman would alert the nurse to the possible presence of osteoporosis? A. Presence of bowed legs B. Measurable loss of height C. Poor appetite and aversion to dairy products D. Development of unstable, wide-gait ambulation
B
For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? A Speaking loudly and slowly B Using a "picture board" for the client to point to pictures C Writing directions so client can read them D Speaking in short sentences
B
On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. Which action is best for the nurse to take? A Explain the reasons for the phantom limb pain. B Administer prescribed analgesics to relieve the pain. C Loosen the compression bandage to decrease incisional pressure. D Remind the patient that this phantom pain will diminish over time.
B
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement? A Adjust the patient-controlled analgesia (PCA) machine for a lower dose. B Ensure the weights of the Buck's traction are off the floor and hang freely. C Raise the head of the bed to 45 degrees and the foot to 15 degrees. D Turn the client on the affected leg using pillows to support the other leg.
B
Which information in a 60-year-old woman's health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system? A The patient experienced a sprained ankle at age 13. B The patients mother became much shorter with aging. C The patients father died of complications of miliary tuberculosis. D The patient reports taking ibuprofen (Advil) for occasional headaches.
B
Which statement by a patient who has had an above-the-knee amputation indicates that the nurses discharge teaching has been effective? A I should elevate my residual limb on a pillow 2 or 3 times a day.BI should lay on my abdomen for 30 minutes 3 or 4 times a day. C I should change the limb sock when it becomes soiled or stretched out. D I should use lotion on the stump to prevent drying and cracking of the skin.
B
The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? A. Central cord syndrome B. Spinal shock syndrome C. Anterior cord syndrome D. Brown-Séquard syndrome
B Rationale: About 50% of people with acute spinal cord injury experience spinal shock, a temporary loss of reflexes, sensation, and motor activity. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.
The nurse is teaching a client about taking prophylactic warfarin sodium(Coumadin). Which statement indicates that the client understands how to take the drug? Select all that apply. A The drug's action peaks in 2 hours B Maximum dosage is not achieved until 3 to 4 days after starting the medication C Effects of the drug continue for 4 to 5 days after discontinuing the medication D Protamine sulfate is the antidote for warfarin E I should have my blood levels tested periodically"
B,C,E
A 68-yr-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation (select all that apply.)? A. Drink more milk. B. Eat 20-30 g of fiber per day. C. Use oral laxatives every day. D. Limit caffeinated beverages. E. Drink 1800 to 2800 mL of water or juice. F. Establish bowel evacuation time at bedtime.
B,D,E Rationale: The patient with a spinal cord injury and neurogenic bowel should eat 20 to 30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Caffeine stimulates fluid loss and can contribute to constipation, so caffeine intake should be limited. Milk also may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless needed. Bowel evacuation time usually is established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.
A patient with kyphosis is scheduled for dual-energy x-ray absorptiometry(DEXA) testing. The nurse will plan to A give an oral sedative. B start an intravenous line. C teach the patient about DEXA. D screen the patient for shellfish allergies.
C
Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? A The patient has dysphasia. B The patient has atrial fibrillation. C The patient states, "My symptoms started with a terrible headache." D The patient has a history of brief episodes of right-sided hemiplegia.
C
During the first 24 hours after thrombolytic treatment from an ischemic stroke, the primary goal is to control the client's: A Pulse B Respirations C Blood Pressure D Temperature
C
Following a motor vehicle accident, a patient arrives in the emergency department with massive right lower leg swelling. Which action will the nurse take first? A Elevate the leg on pillows. B Apply a compression bandage. C Check leg pulses and sensation. D Place ice packs on the lower leg.
C
The nurse determines dietary teaching for a 75-yr-old patient with osteoporosis has been successful when the patient selects which meal as highest in calcium? A. Chicken stir fry with 1 cup each onions and green peas, and 1 cup of steamed rice B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple C. Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk D. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit
C
The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery? A Pain B Left knee stiffness C Left knee infection D Left knee instability
C
The nurse is completing discharge teaching with an 80-yr-old male patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed? A Uses an elevated toilet seat B Sits with feet flat on the floor C Maintains hip in adduction and internal rotation D Verifies need to notify future caregivers about the prosthesis
C
The nurse is planning psychosocial support for the family of the patient who suffered a stroke. What factor will have the greatest impact on family coping? A Specific patient neurologic deficits B The patient's ability to communicate C Rehabilitation potential of the patient D Presence of complications of a stroke
C
When counseling an older patient about ways to prevent fractures, which information will the nurse include? A Tack down scatter rugs in the home. B Most falls happen outside the home. C Buy shoes that provide good support and are comfortable to wear. D Range-of-motion exercises should be taught by a physical therapist.
C
When the nurse is assessing a new patient in the clinic, which information about the patients medications will be of most concern? A The patient takes a daily multivitamin and calcium supplement. B The patient has migraine headaches that are treated with nonsteroidal anti-inflammatory drugs(NSAIDs). C The patient has severe asthma and requires frequent therapy with oral steroids. D The patient takes hormone replacement therapy (HRT) to prevent hot flashes.
C
Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A Overestimation of physical abilities B Difficulty judging position and distance C Slow and possibly fearful performance of tasks D Impulsivity and impatience at performing tasks
C
Which sensory-perceptual deficit is associated with left-sided stroke (righthemiplegia)? A Overestimation of physical abilities B Difficulty judging position and distance C Slow and possibly fearful performance of tasks D Impulsivity and impatience at performing tasks
C
The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? A. Pain assessment B. Glasgow Coma Scale C. Respiratory assessment D. Musculoskeletal assessment
C Rationale: Although all the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure requires vigilant monitoring of the patient's respiratory function.
Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Check for bowel impaction C. Elevate the head of the bed D. Administer intravenous hydralazine
C Rationale: Positioning the patient upright is the first action so blood pressure will decrease. Then assessment of indwelling urinary catheter patency or immediate catheterization should be performed to relieve bladder distention. Next, the rectum should be examined for retained stool or impaction. Finally, the nurse will consider administering an intravenous antihypertensive medication if needed.
A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she experiences bowel incontinence two or three times each day. Which action by the nurse is most appropriate? A. Insert a rectal stimulant suppository. B. Teach the patient to gradually increase intake of high-fiber foods. C. Assess bowel movements for frequency, consistency, and volume. D. Instruct the patient to avoid all caffeinated and carbonated beverages.
C Rationale: The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited but need not be eliminated. After stabilization, creation of a bowel program including a rectal stimulant, digital stimulation, or manual evacuation at the same time each day will regulate bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.
A 25-yr-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority when planning for rehabilitation? A. Prevent urinary tract infection. B. Monitor the patient every 15 minutes. C. Encourage him to verbalize his feelings. D. Teach him about using the gastrocolic reflex.
C Rationale: To help the patient with coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages self-expression and verbalization of thoughts and feelings. The patient is at high risk for depression and self-injury because loss of function below the umbilicus is expected. He is a young adult male patient who will likely need a wheelchair and have impaired sexual function. Resuming a racing career is unlikely. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits and can make coping difficult. Preventing urinary tract infection and facilitating bowel evacuation with the gastrocolic reflex will be important during recovery. In rehabilitation, monitoring every 15 minutes is not needed unless the patient is on suicide precautions.
In which order will the nurse take these actions when caring for a patient with left leg fractures after a motor vehicle accident? A. Obtain x-rays. B. Check pedal pulses. C. Assess lung sounds. D. Take blood pressure. E. Apply splint to the leg. F. Administer tetanus prophylaxis.
C,D,B,E,A,F
When entering the grocery store, a patient trips on the curb and sprains the right ankle. Which initial care is appropriate (select all that apply.)? A Apply ice directly to the skin. B Apply heat to the ankle every 2 hours. C Administer antiinflammatory medication. D Compress ankle using an elastic bandage. E Rest and elevate the ankle above the heart. F Perform passive and active range of motion.
C,D,E
The nurse formulates a nursing diagnosis of Impaired physical mobility related to decreased muscle strength for an older adult patient recovering from left total knee arthroplasty. What nursing intervention is appropriate? A Promote vitamin C and calcium intake in the diet. B Provide passive range of motion to all of the joints q4hr. C Keep the left leg in extension and abduction to prevent contractures. D Encourage isometric quadriceps-setting exercises at least four times a day.
D
A 58-year-old woman who has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman about her osteoporosis, the nurse explains that A estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. B continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. C with a family history of osteoporosis, there is no way to prevent or slow gradual bone resorption. D calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.
D
A 67-yr-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges and elevation of the affected foot on two pillows. The nurse would place the highest priority on which intervention? A. Ambulate the patient to the bathroom every 2 hours. B. Ask the patient about preferred activities to relieve boredom. C. Allow the patient to dangle legs at the bedside every 2 to 4 hours. D. Perform frequent position changes and range-of-motion exercises.
D
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 Administer a bisacodyl (Dulcolax) rectal suppository every day. D Arrange for several servings per day of cooked fruits and vegetables.
D
A nurse is providing education to a patient with a recent diagnosis of a transient ischemic attack (TIA). Which of the statements by the patient indicates that the patient understands the information? A "Because TIAs don't cause permanent damage, I don't need to worry about having another one" B "TIAs are usually caused by large bleeds in the brain that resolve on their own" C "TIAs are usually caused by small bleeds in the brain that resolve on their own" D "It's important to seek medical attention immediately if I experience these symptoms again because it means I could be having a stroke"
D
A nurse is teaching a client who had a stroke about ways to adapt to a visual disability while ambulating. Which does the nurse identify as the primary safety precaution to use? A Wear a patch over one eye B Place personal items on the sighted side C Lie in bed with the unaffected side toward the door D Turn the head from side to side when walking
D
A patient is admitted to the emergency department with possible left lower leg fractures. The initial action by the nurse should be to A elevate the left leg. B splint the lower leg. C obtain information about the tetanus immunization status. D check the popliteal, dorsalis pedis, and posterior tibial pulses.
D
A patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's husband is visiting, he feeds and dresses the wife. Which nursing diagnosis is most appropriate for the patient? A Interrupted family processes related to effects of illness of a family member B Situational low self-esteem related to increasing dependence on spouse for care C Impaired nutrition: less than body requirements related to hemiplegia and aphasia D Disabled family coping related to inadequate understanding by patient's spouse
D
A patient with a comminuted fracture of the right femur has Bucks traction in place while waiting for surgery. To assess for pressure areas on the patients back and sacral area and to provide skin care, the nurse should A loosen the traction and have the patient turn onto the unaffected side. B place a pillow between the patients legs and turn gently to each side. C turn the patient partially to each side with the assistance of another nurse. D have the patient lift the buttocks by bending and pushing with the left leg.
D
A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find? A Impulsive behavior B Right Sided Neglect C Hyperactive left-sided reflexes D Difficulty in understanding commands
D
A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery? A Place the right thumb directly on some ice. B Put the right thumb in a glass of warm water C Wrap the thumb in a clean piece of material. D Secure the thumb in a plastic bag and place on ice.
D
The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A 92-yr-old female patient who takes warfarin (Coumadin) for atrial fibrillation B 28-yr-old male patient who uses marijuana after chemotherapy to control nausea C 42-yr-old female patient who takes oral contraceptives and has migraine headaches D 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco
D
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 (Coumadin) for atrial fibrillation B A 28-yr-old male patient who uses marijuana after chemotherapy to control nausea C A 42-yr-old female patient who takes oral contraceptives and has migraine headaches D A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco
D
The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/LVN? A Assess skin integrity around the traction boot. B Determine correct body alignment to enhance traction. C Remove weights from traction when turning the patient. D Monitor pain intensity and administer prescribed analgesics.
D
The nurse is reinforcing health teaching about osteoporosis with a 72-yr-old patient admitted to the hospital. What should the nurse explain to the patient? A. With a family history of osteoporosis, you cannot prevent or slow bone resorption. B. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. C. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise
D
The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A "Take the person to the hospital if a headache lasts for more than 24 hours." B "Stroke symptoms usually start when the person is awake and physically active." C "A person with a transient ischemic attack has mild symptoms that will go away." D "Call 911 immediately if a person develops slurred speech or difficulty speaking."
D
The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old woman with an ischemic stroke. Which action by the student will require the nurse to intervene? A Giving the patient 1 oz 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
The patient is brought to the emergency department after a car accident and is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? A Administer enoxaparin (Lovenox). B Provide range-of-motion exercises. C Apply sequential compression boots. D Immobilize the fracture preoperatively.
D
This morning a 21-yr-old male patient had a long leg cast applied, and he asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? A "No one is available to assist and accompany the patient." B "The cast is not dry yet, and it may be damaged while using crutches." C "Rest, ice, compression, and elevation are in process to decrease pain." D "Excess edema and complications are prevented when the leg is elevated for 24 hours."
D
When assessing a 64-year-old woman, the nurse notes that the patient has lost1 inch in height since the previous visit 2 years ago. The nurse will plan to teach the patient about A discography studies. B myelographic testing. C magnetic resonance imaging (MRI). D dual-energy x-ray absorptiometry (DEXA).
D
Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? A Present several thoughts at once so that the patient can connect the ideas. B Ask open-ended questions to provide the patient the opportunity to speak. C Finish the patient's sentences to minimize frustration associated with slow speech. D Use simple, short sentences accompanied by visual cues to enhance comprehension.
D
Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? A Present several thoughts at once so that the patient can connect the ideas. B Ask open-ended questions to provide the patient the opportunity to speak. C Finish the patient's sentences to minimize frustration associated with slow speech. D Use simple, short sentences accompanied by visual cues to enhance comprehension.
D
Which menu choice by a patient with osteoporosis indicates that the nurses teaching about appropriate diet has been effective? A Pancakes with syrup and bacon B Whole wheat toast and fruit jelly C Two-egg omelet and a half grapefruit D Oatmeal with skim milk and fruit yogurt
D
When planning care for a patient with a cervical spinal cord injury (C5), which nursing diagnosis has the highest priority? A. Impaired urinary elimination related to tetraplegia B. Risk for impaired tissue integrity related to paralysis C. Disabled family coping related to the extent of trauma D. Ineffective airway clearance related to cervical spinal cord injury
D Rationale: Maintaining a patent airway is the most important goal for a patient with a cervical spinal cord injury. Although all are appropriate nursing diagnoses for a patient with a cervical spinal cord injury, respiratory needs are always the highest priority (ABCs).
A patient learns about rehabilitation for a spinal cord tumor. Which statement by the patient reflects appropriate understanding of this process? A. "I want to be rehabilitated for my daughter's wedding in 2 weeks." B. "Rehabilitation will be more work done by me alone to try to get better." C. "I will be able to do all my normal activities after I go through rehabilitation." D. "With rehabilitation, I will be able to function at my highest level of wellness."
D Rationale: Rehabilitation is an interprofessional endeavor to teach and enable the patient to function at his or her highest level of wellness and adjustment. Intense work will be required of all involved persons; the process will take longer than 2 weeks. With neurologic dysfunction, the patient will not be able to perform all normal activities at the same level as previously.
