nclex challenge 8

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Position the child side-lying. This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Protein Protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing.

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctivae To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, conjunctivae, and mucous membranes.

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

"Move objects away from the client." The nurse should instruct the family to move objects away from the client to reduce the risk of injury to the client.

A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?

Apply a protective boot to the right ankle. The nurse should apply padded splints or protective boots to the right ankle to keep the foot at a right angle to the leg to prevent footdrop.

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Talk the client through tasks one step at a time. The nurse should plan to talk the client through tasks one step at a time to minimize confusion and promote independence, which will decrease the client's anxiety level.

A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles?

Autonomy The issue here is the client's right to choose. The ethical principle of autonomy applies to an individual's right to choose and control what happens to him. Respecting autonomy requires the nurse to recognize the client's choice is based on personal values and those values do not have to be shared by the nurse.

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV (trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial nerve is functioning properly, the expected reaction is pupil constriction in response to light.

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.

A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area?

Montgomery straps Montgomery straps are adhesive strips that are applied to the skin on either side of the surgical wound. The strips have holes so the two sides of the dressing can be tied together and re-opened for dressing changes without having to remove the adhesive strips. If Montgomery straps are unavailable, the nurse can place strips of hydrocolloid dressing on either side of the wound and place the tape across the dressing onto the hydrocolloid strips.

A nurse in a dermatologist's office is planning an educational session about skin cancer. Which of the following should the nurse include as risk factors for skin cancer? (Select all that apply.)

Overexposure to ultraviolet light previous skin injury genetic predisposition

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?

Prepare the client for mechanical ventilation. The client who is experiencing a myasthenic crisis is at risk for loss of adequate respiratory function. The nurse should closely monitor the client's respiratory status and prepare for possible mechanical ventilation.

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?

The client If the client appears competent, and understands the procedure, the client can sign for informed consent. The nurse should verify that the client gives consent voluntarily, the signature on the consent is the client's, and the client appears competent. If the client were disoriented and not competent, the person who has durable power of attorney should sign informed consent.

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Weakness Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory distress or predispose the client to respiratory infections.

A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention?

"How do you handle stress?" Although stress can play a role in creating or exacerbating a skin condition, this question does not obtain specific information that relates to the skin condition.

A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching?

"I will monitor my husband for tilting his head forward when he swallows." A client who tilts his head forward while eating reduces the risk for dysphagia

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

"I'll be glad when I can stop taking this medicine." Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on anticonvulsant medications commonly require them for lifetime administration, and phenytoin should not be stopped without the advice of the client's provider.

A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following information should the nurse include in the teaching?

"Syncope episodes may occur when taking this medication." The nurse should inform the family to monitor for syncope, which places the client at risk for falling.

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves. The greatest risk to the client is from increased intracranial pressure (ICP) which may lead to herniation of the brain and death. The nurse should perform neurological assessments including evaluation of the cranial nerves at least every 4 hr. Early neurological changes to be monitoring for include a decrease in the level of consciousness, the development of Cushing's triad (severe hypertension, widened pulse pressure, and bradycardia), and changes in pupillary reaction.

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take?

Assist the client to the correct room. Assisting the client to the correct room protects both clients. It helps reorient the client who is unable to find her own room, and it protects the other client from an invasion of her personal space.

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?

Cover the wound with a moist, sterile gauze dressing. The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Decreased level of consciousness As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness, decrease. Other manifestations include severe headache, irritability, and pupils that are slow to react or are unreactive to light.

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Dispose of the dressing in a biohazardous waste container. The nurse should discard potentially infective material, such as a dressing that contains blood and pus, in a biohazardous materials container separate from the regular trash.

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

Grilled salmon Poultry, fish, eggs, and beef are complete proteins and are optimal sources of protein to support wound healing.

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Manifestations preceded by a severe headache A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke.

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

Muscle contractions become progressively stronger. A positive Tensilon test is indicated by a 4 to 5 min period of improved muscle tone and strength.

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)

Muscle distortion pain behind the ear impaired taste

A nurse is developing a plan of care for a client following a lumbar puncture. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Provide Oral Fluids Monitor for Nausea Check level of consciousness check sensation in the toes

A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

Provide a consistent daily routine. A consistent daily routine is appropriate for the care of a client who has Alzheimer's disease.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Provide client supervision. Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment.

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Provide the client with a diet high in protein. Inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown.

A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse take to maintain privacy for the client?

Pull the curtains around the client's bed. Pulling the curtains around the client's bed assures privacy for the client should someone open the door or enter the room.

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority?

Schedule a follow-up visit by a home health nurse for dressing changes. The greatest risk to this client is injury from a wound infection. Therefore, the priority action the nurse should take is to schedule a follow-up visit by a home health nurse for dressing changes. Wounds healing by secondary intention are open and have edges that are not approximated, which increases the risk for infection.

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous Watery red drainage should be documented as serosanguineous.

A nurse is assessing a client who has a new skin lesion that has a wavy border. The nurse should document the lesion using which of the following descriptions?

Serpiginous Serpiginous lesions have wavy borders that resemble a snake.

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing?

Serum albumin 3.2 g/dL A serum albumin level is a good indicator of the nutritional status of a client. A value less than 3.5 g/dL is an indication of poor nutrition, can delay wound healing, and lead to infection.

A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching?

race

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)

contractures of the extremities crackles in the lungs pressure ulcers

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

"Eating a high fiber diet will reduce my risk for developing skin cancer." A high-fiber diet is recommended to reduce the risk for colon cancer.

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

"Have you had a recent influenza infection?" The nurse should ask the client about a recent Haemophilus influenzae infection. The cause of GBS is unknown, but it usually follows a viral infection.

A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

"Incorporate nonverbal cues in the conversation." Nonverbal cues enhance the client's ability to comprehend and use language.

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

A reddened area over the sacrum A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

Encourage the client to take small bites. The family members should encourage the client to take small bites and chew food thoroughly in order to prevent choking.

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?

Evaluate the client's neurological status. Manifestations of a headache and stiff neck (nuchal rigidity) are indications that the client might have meningitis. The greatest risk to the client is injury from increased intracranial pressure, which can lead to brain herniation and death. Therefore, the nurse should complete a neurological assessment as a baseline. If the client does have meningitis, neurological checks should be completed every 2 to 4 hr.

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?

Hemorrhagic stroke A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including sudden onset of a severe headache, a decrease in the level of consciousness, and seizures. Hemorrhagic strokes occur when bleeding occurs in the brain caused by the rupture of an aneurysm or arteriovenous malformation, hypertension and atherosclerosis, or trauma.6

A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Instruct the client to look up and down without moving his head. The nurse should observe the client's extraocular eye movements by instructing him to look at the cardinal fields of gaze as part of an evaluation of the function of cranial nerve III (Oculomotor).

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?

Restlessness Clients who have meningitis can be at risk for developing increased ICP. The nurse should monitor the client's vital signs and neurological status at least every four hours. Indications of increased ICP include increased restlessness and confusion, a decreased level of consciousness, and the presence of Cushing's triad (severe hypertension, widened pulse pressure, and bradycardia).

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Restlessness Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.

A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include?

"Use contraception while taking this medication." Sumatriptan can cause teratogenesis and should not be used during pregnancy.

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

An older adult who has a hip fracture and is in Buck's traction According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown.

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication?

Ask the client to take a few sips of water. Clients who have myasthenia gravis, an autoimmune disorder, have weakness of the muscles of the face and throat, which increases the risk for aspiration. The nurse should check the client's ability to swallow before administering oral medication.

A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse's priority?

Ask the partner to talk about his difficulties in caring for the client. The first action the nurse should take using the nursing process priority framework is to assess the partner's difficulties in caring for his wife.

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

Basal cell carcinoma A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent, pearly borders. Telangiectatic vessels can also be present. As a basal cell tumor grows, it can undergo central ulceration.

A nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. Which of the following should the nurse include in the teaching as manifestations seen in the moderate stage of Alzheimer's disease? (Select all that apply.)

Inability to perform common tasks Difficulty with talking or reading

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to. A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

The partner has lost 20 lb in the past 2 months. A large weight loss by the caregiver is an indication of caregiver role strain.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration.

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Use a transfer device to lift the client up in bed Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Use pillows to keep heels off the bed surface. Minimize skin exposure to moisture.