medsurge chapter 14
A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which of the following actions should the health care team take in order to promote adequate nutrition for this patient?
Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow
A patient has been blind for the past 10 years. He is hospitalized with congestive heart failure (CHF). In the care of a long-term blind individual, it is important to
The nurse should announce when entering or leaving the room, so that a blind person is not put in the position of talking to someone who is no longer there.
Which of the following nursing interventions is most appropriate when communicating with a patient suffering from aphasia poststroke? 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) Use simple, short sentences accompanied by visual cues to enhance comprehension. D) Finish the patient's sentences so as to minimize frustration associated with slow speech.
When communicating with a patient with aphasia, the nurse should present one thought or idea at a time; ask questions that can be answered with a "yes," "no," or simple word; use visual cues; and allot time for the individual to comprehend and respond to conversation.
When teaching a patient about the pathophysiology related to open-angle glaucoma, which of the following statements is most appropriate?
With primary open-angle glaucoma, there is increased intraocular pressure because the aqueous humor cannot drain from the eye. This leads to damage to the optic nerve over time.
The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which of the following medications might the nurse expect to provide discharge instructions (select all that apply)? A) Clopidogrel (Plavix) B) Enoxaparin (Lovenox) C) Dipyridamole (Persantine) D) Enteric-coated aspirin (Ecotrin) E) Tissue plasminogen activator (tPA)
a, c, d
A patient with a suspected closed head injury has bloody nasal drainage. The nurse suspects that this patient has a cerebrospinal fluid (CSF) leak when observing which of the following?
A) A halo sign on the nasal drip pad
A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of her head. Which of the following assessments should the nurse complete prior to this diagnostic study? A) Assess the patient's immunization history. B) Screen the patient for any metal parts or a pacemaker. C) Assess the patient for allergies to shellfish, iodine, or dyes. D) Assess the patient's need for tranquilizers or antiseizure medications.
c.Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT.
The three components of Cushing's response are: (Select all that apply.) A) Increased pulse rate B) Increased blood pressure C) Widened pulse pressure D) Bradycardia E) Increased systolic blood pressure F) Uncontrolled thermoregulation
A widened pulse pressure, increased systolic blood pressure, and bradycardia are together called Cushing's response. c d e
Astigmatism is a medical term meaning which visual disorder? A) Blurred vision B) Inability to detect colors C) Color blindness D) Farsightedness
A) Blurred vision
For which of the following patients should the nurse prioritize an assessment for depression? A) a. A patient in the early stages of Alzheimer's disease B) b. A patient who is in the final stages of Alzheimer's disease C) c. A patient experiencing delirium secondary to dehydration D) d. A patient who has become delirious following an atypical drug response
A, Patients in the early stages of Alzheimer's disease are particularly susceptible to depression
Which foods may worsen headaches? (Select all that apply.) A) Yogurt B) Caffeine C) Beef D) Pears E) Marinated foods F) Milk
A,B&E Some foods may cause or worsen headaches. Foods that may provoke headaches include vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork.
The most common cause of congenital hearing loss from birth or early infancy is: A) Anoxia or trauma B) Tumor C) Infection D) Occasional loud noise
A. Congenital hearing loss is present from birth or early infancy. Anoxia or trauma during delivery may be causes.
A hearing-impaired patient is having problems communicating with staff members. Which behaviors would continue to hinder communication? A) Overaccentuating words B) Facing the patient when speaking C) Speaking in conversational tones D) Speaking into the affected ear
A. Do not overaccentuate words. Speak in a normal tone; do not shout or raise the pitch of voice.
The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which of the following assessments should the nurse prioritize? A) a. Pain assessment B) b. Glasgow Coma Scale C) c. Respiratory assessment D) d. Musculoskeletal assessment
Although all of the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status.
Ergotamine tartrate medications are beneficial in migraine headaches because they A) dilate cerebral blood vessels. B) constrict cerebral blood vessels. C) reduce neurotransmission of pain impulses. D) enhance endorphin secretion.
B) constrict cerebral blood vessels.
The nurse is caring for a patient admitted with a spinal cord injury following 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
B)Spinal shock syndrome
The nurse would expect to find which of the following clinical manifestations in a patient admitted with a left-brain stroke? A) Impulsivity B) Impaired speech C) Left-side neglect D) Short attention span
B. Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language aphasias, impaired right/left discrimination, and slow and cautious performance.
How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury? A) Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together. B) Ask the patient to maintain balance while standing with his or her feet together and eyes closed. C) Ask the patient to close his or her eyes and identify the presence of a common object on the forearm
B.The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance
When administering eye drops to a patient with glaucoma, which of the following nursing measures is most appropriate to minimize systemic effects of the medication? A) a. Apply pressure to each eyeball for a few seconds after administration. B) b. Have the patient close the eyes and move them back and forth several times. C) c. Have the patient put pressure on the inner canthus of the eye after administration
C) c. Have the patient put pressure on the inner canthus of the eye after administration
The earliest sign of increased intracranial pressure is A) headache. B) dilated pupil. C) decreasing level of consciousness. D) diplopia (double vision).
C) decreasing level of consciousness
Benzodiazepines are indicated in the treatment of cases of delirium that have which of the following causes? A) a. Polypharmacy B) b. Cerebral hypoxia C) c. Alcohol withdrawal D) d. Electrolyte imbalances
C. Benzodiazepines can be used to treat delirium associated with sedative and alcohol withdrawal. However, these drugs may worsen delirium caused by other factors and must be used cautiously.
A 32-year-old construction worker has suffered a penetrating wound to his right eye. The best intervention for anyone to perform at the scene while waiting to be transported to the hospital is to A) gently remove the object. B) wipe away the blood and tears. C) cover both eyes with a paper cup and tape. D) do nothing; rush to the hospital.
C. Cover both eyes with a paper cup & tape
A method of reducing a person's risk of becoming infected with the West Nile virus would be to A) wear shorts and short-sleeve shirts. B) apply baby lotion to all extremities. C) apply insect repellent that contains DEET. D) apply flea and tick repellent.
C. One can reduce the risk of becoming infected with West Nile virus by applying insect repellent to exposed skin. Choose an insect repellant that contains diethyltoluamide (DEET) and one that provides protection for the amount of time you will be outdoors.
Which of the following sensory-perceptual deficits is associated with left-brain 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. Patients with a left-brain stroke commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-brain stroke.
A patient has a history of tonic-clonic seizures. She was admitted to the neurological unit after having had three tonic-clonic seizures in the past 2 days. Her husband reported that she had been sleeping for long periods af
D Seizures are followed by a rest period of variable length, called a postictal period.
A patient has been complaining of headaches. If the headaches are migraine, the nurse would expect to assess that the headaches: A) They are observed during times of stress. B) They become worse toward evening. C) They have their onset when the person is in his or her twenties or thirties. D) They may cause unusual smells or sounds for the patient before the pain begins.
D) They may cause unusual smells or sounds for the patient before the pain begins.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A) a. Risk for impairment of tissue integrity caused by paralysis B) b. Altered patterns of urinary elimination caused by quadriplegia C) c. Altered family and individual coping caused by the extent of trauma D) d. Ineffective airway clearance caused by high cervical spinal cord injury
D) d. Ineffective airway clearance caused by high cervical spinal cord injury
A patient has been injured in a motorcycle accident and is presenting with signs and symptoms of increased intracranial pressure. What is the most significant sign or symptom of increased intracranial pressure? A) Pupil changes B) Ipsilateral paralysis C) Vomiting D) Decrease in the level of consciousness
D. Collection of objective data includes a change in level of consciousness. c. A change in the level of consciousness is the earliest sign of increased intracranial pressure.
When the eye adjusts to seeing objects at various distances, it is called A) PERRLA. B) refraction. C) focusing. D) accommodation.
D. Accommodation: The eye is able to focus on objects at various distances.
Which of the following patients may face the greatest risk of developing delirium? A) a. A patient with fibromyalgia whose chronic pain has recently worsened B) b. An elderly patient whose recent computed tomography shows brain atrophy C) c. A patient with a fracture who has spent the night in the emergency department D) d. An elderly patient who takes multiple medications for various health problems
D. Polypharmacy is implicated in many cases of delirium, and this phenomenon is especially common among older adults. Brain atrophy, if associated with cognitive changes, is indicative of dementia.
The patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for which of the following?
Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech.
When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm demonstrated by downward drifting of the arm. The nurse would most accurately document this finding as
Downward drifting of the arm or pronation of the palm is identified as a pronator drift. Hemiparesis is weakness of one side of the body; hypotonia defines a flaccid muscle tone; and athetosis is a slow, writhing, involuntary movement of the extremities.
A patient is prescribed eyedrops that constrict the pupil, permitting aqueous humor to flow. The nurse would reinforce the teaching by referring to the drops as A) mydriatics. B) miotics. C) osmotics. D) inhibitors.
Miotics are agents that cause the pupil to contract or constrict.
A patient, age 52, is brought to the emergency department by ambulance after she hit her head on her bathroom sink and fell unconscious to the floor. Which assessment should the nurse perform first? A) History of health problems B) Patency of airway
Nursing diagnosis and interventions for the patient with a severe head injury may include Ineffective breathing pattern related to neuromuscular impairment. Nursing interventions will be to maintain a patent airway.
A patient, age 69, is being evaluated by a neurologist for signs of muscle rigidity, masklike face (area from forehead to chin), and propulsive gait. These signs are often characteristic of
Parkinsonism is a syndrome that consists of bradykinesia, rigidity, tremor, and impaired postural reflexes.
As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which would best describe the patient's inability to assess spatial position of his body? A) Agnosia B) Proprioception C) Apraxia D) Sensation
Patients may experience a loss of proprioception with a stroke. This may include apraxia and agnosia (a total or partial loss of the ability to recognize familiar objects or people).
The best prevention of serious complications of ear disorders like infections, mastoiditis and brain abscesses is: A) Strong antibiotics and isolation B) Early detection and treatment C) Surgery and rehabilitation D) Bed rest and early speech reading techniques
Prevention of serious complications of ear disorders—such as infections, mastoiditis, and brain abscess—requires early detection and treatment.
A patient visits the physician for a routine physical examination that involves testing distance vision. As she faces the Snellen chart, the nurse is to instruct the patient to A) use both eyes to read the chart. B) read the chart from right to left. C) cover one eye while testing the other. D) use any one eye since they will be the same.
c. A major diagnostic eye test is the Snellen test. While instructing a patient to perform this test, the nurse will have the patient stand or sit 20 feet from the chart and cover one eye to read the letters on the chart.
The best nursing intervention for restlessness in a patient with a head injury is A) sedation with an available narcotic. B) restraints to prevent injury. C) assessing for pain or distended bladder. D) encouraging verbalization of the problem.
c. Behavioral problems associated with a lack of judgment and restlessness may also occur. Restlessness in the head-injured patient may be caused by the need for a change of position, pain, or the need to empty the bladder.
When the seriousness of craniocerebral trauma is assessed, it is important to remember that A) heavy scalp bleeding indicates serious trauma. B) open injuries are always more serious than closed injuries. C) signs and symptoms may not occur until several days after the trauma. D) trauma to the frontal lobe is more significant than to any other area.
c. If a patient who has been conscious for several days after head injury loses consciousness or develops neurological signs and symptoms, a subdural hematoma should be suspected.
Which of the following nursing diagnoses is likely to be a priority in the care of a patient with myasthenia gravis (MG)? A) Acute confusion B) Bowel incontinence C) Activity intolerance D) Disturbed sleep pattern
c. The primary feature of MG is fluctuating weakness of skeletal muscle. Activity intolerance is usually of primary concern.
A patient has an infectious/inflammatory process of the eyelid. The primary goal of nursing intervention is
prevent further infection
Select all the conditions that may cause conductive hearing loss. A) Buildup of cerumen B) Foreign bodies C) Otosclerosis of external auditory canal D) Trauma E) Exposure to ototoxic drugs F) Otitis media with effusion
A) Buildup of cerumen B) Foreign bodies C) Otosclerosis of external auditory canal F) Otitis media with effusion
Sjögren's syndrome is associated with which eye disorder? A) Keratoconjunctivitis sicca B) Conjunctivitis C) Blepharitis D) Opaque lens disorder
A) Keratoconjunctivitis sicca
Which of the following nursing actions should be implemented in the care of a patient who is experiencing increased intracranial pressure (ICP)? A) Monitor fluid and electrolyte status astutely. B) Position the patient in a high Fowler's position. C) Administer vasoconstrictors to maintain cerebral perfusion. D) Maintain physical restraints to prevent episodes of agitation.
A. Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances.
Which of the following modifiable risk factors 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. Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated.
Which of the following findings related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report?
A. absence of pain Primary open-angle glaucoma is typically symptom free, which explains why patients can have significant vision loss before diagnosis unless regular eye examinations are being performed.
Astigmatism is a medical term meaning which visual disorder? A) Blurred vision B) Inability to detect colors C) Color blindness D) Farsightedness
A. blurred vision
Which of the following measures should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? A) Vigilant infection control and adherence to standard precautions B) Careful monitoring of neurologic vital signs and frequent reorientation C) Maintenance of a calorie count and hourly assessment of intake and output D) Assessment of blood pressure and monitoring for signs of orthostatic hypotension
A.Infection control is a priority in the care of patients with MS, since infection is the most common precipitator of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in hypotension or fluid volume excess or deficit.
A patient has a head injury and is presenting with signs and symptoms of increased intracranial pressure. Which nursing intervention would be helpful in reducing this pressure? A) Place the neck in a neutral position to promote venous drainage. B) Suction hourly to stimulate the cough reflex.
A.Place the neck in a neutral position (not flexed or extended) to promote venous drainage.
The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which of the following complications (select all that apply)? A) Vision loss B) Cerebral edema C) Pituitary dysfunction D) Parathyroid dysfunction E) Focal neurologic deficits
ABCE,Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure (ICP) and cerebral edema can appear.
Important nursing measures needed when feeding a hemiplegic patient include: (Select all that apply.) A) Mixing liquids and solid foods together B) Taking the patient's dentures out to prevent choking C) Checking the affected side of mouth for food accumulation D) Offering small bites of food E) Elevating the patient to no more than 30 degrees F) Adding a thickening agent to liquids
cdf. Important nursing measures include avoiding foods that cause choking, checking the affected side of the mouth for accumulation of food and resultant poor hygiene, not mixing liquids and solid foods, and encouraging the patient to take small bites.
What factors must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired? (Select all that apply.) A) Cultural beliefs B) Values C) Habits D) Income E) Occupation
culture, values & habit
In the aging process, older adults are able to A) react to events immediately. B) master new material quickly. C) remember information from the immediate present (short-term memory). D) learn new skills.
d. learn new skills Most older people possess the ability to learn, but the speed of learning is slowed. Short-term memory is more affected with age