Prep Questions for Final
The nurse is evaluating the status of the client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A negative Kernig's sign Absence of nuchal rigidity A positive Brudzinski's sign A Glasgow Coma Scale score of 15
A positive Brudzinski's sign
The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? A pink-colored tympanic membrane A pearly colored tympanic membrane A transparent and clear tympanic membrane A red, dull, thick, and immobile tympanic membrane
A red, dull, thick, and immobile tympanic membrane
A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? No change in the condition Complaints of muscle spasms A improvement of the weakness A temporary worsening of the condition
A temporary worsening of the condition
The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote should the nurse prepare for administration if prescribed? Pentostatin Auranofin Fludarabine Acetylcysteine
Acetylcysteine
A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse determine could be the cause of the client's complaint? Doxycycline Atropine sulfate Acetysalicylic acid Diltiazem hydrochloride
Acetysalicylic acid
A patient being cared for on the neurologic unit has a diagnosis of acute ischemic stroke. It has affected the left hemisphere of the patient's brain. The nurse would expect to assess which deficit in this patient? Left side of body weakness Aphasia Left field visual deficit Lack of awareness of deficits
Aphasia
The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately? Apply ice to the affected eye Irrigate the eye with cool water Notify the PHCP Accompany the client to the emergency department
Apply ice to the affected eye
Which medication, if prescribed for the client with glaucoma, should the nurse question? Betaxolol Pilocarpine Erythromycin Atropine sulfate
Atropine sulfate
The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. Avoid activities that require bending over Contact the surgeon if eye scratchiness occurs Take acetaminophen for minor eye discomfort Expect episodes of sudden severe pain in the eye Place an eye shield on the surgical eye at bedtime Contact the surgeon if a decrease in visual acuity occurs
Avoid activities that require bending over Take acetaminophen for minor eye discomfort Place an eye shield on the surgical eye at bedtime Contact the surgeon if a decrease in visual acuity occurs
A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? Increase sodium in the diet Avoid sudden head movements Lie still and watch the television Increase fluid intake to 3000 mL a day
Avoid sudden head movements
A patient admitted to the emergency room has a history of a spinal tumor. Which sign and symptom should alert the nurse to the possibility of SCC? Seizures Headache Back pain Diplopia
Back pain
The nurse notices clear fluid draining from the nose of a patient who sustained a head injury 2 hours ago. This may indicate the presence of what condition? Cerebral concussion Basal skull fracture Brain tumor Sinus infection
Basal skull fracture
A patient, who is seen in the vision clinic, has been diagnosed with glaucoma. What initial topical medication would the nurse expect to be included in the treatment plan for this patient? Mydriatic Antifungal Beta blocker Miotic
Beta blocker
How might a patient with tinnitus describe hearing sound to the nurse? Sputtering Muffled Loud Buzzing
Buzzing
A patient with Parkinson disease is seen in the neurology clinic for treatment. The nurse identifies this disorder as being caused by a lack of which neurotransmitters? Acetylcholine Dopamine Serotonin Gamma-aminobutyric acid (GABA)
Dopamine
A patient is undergoing a cerebral angiography to rule out an aneurysm. When preparing the patient for the procedure, what would the nurse include in the instructions? Expect a metallic taste when the contrast agent is injected. You will need a full bladder prior to the procedure. Maintain an NPO status. General sedation will be given prior to procedure.
Expect a metallic taste when the contrast agent is injected.
A 56-year-old patient who is hearing-impaired is scheduled for a colonoscopy. Which nursing action is most appropriate in performing patient education prior to the procedure? Face the patient directly, smile, and speak slowly. Continue to administer medications while educating the patient. Nod to make up for awkward silence, even if you don't know what is being said. Use only gestures to communicate the highlights of content to be covered.
Face the patient directly, smile, and speak slowly.
What is a late sign of rising ICP? Papilledema Change in the LOC Vomiting Hypertension
Hypertension
What would the nurse expect to document in a patient diagnosed with a right hemispheric stroke? Aphasia Slow, cautious behavior Right visual field deficit Impulsive behavior
Impulsive behavior
The nurse is caring for the client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising? Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
A patient has just been admitted to the hospital with a diagnosis of brain tumor. She makes a comment that drinking alcohol has caused her brain tumor. What does the nurse understand to be a cause of brain tumor? Smoking Ionizing radiation Diet high in fat Exposure to the sun
Ionizing radiation
What manifestations will the nurse observe in the patient undergoing a tonic-clonic seizure? Jerking in one extremity that spreads gradually to adjacent areas Vacant staring and abrupt cessation of all activity Facial grimaces, patting motions, and lip smacking Loss of consciousness, body stiffening, and violent muscle contractions
Loss of consciousness, body stiffening, and violent muscle contractions
A patient is admitted with a closed head injury that was sustained in a motorcycle accident. The patient has been showing an upward trend in ICP measurements. What is the first priority action that the nurse should take with this patient? Administer 100 mg of IV pentobarbital as ordered Increase the ventilator settings to a respiratory rate of 20 breaths/min Administer 20 g of IV mannitol as ordered Reposition the patient to avoid neck flexion
Reposition the patient to avoid neck flexion
The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Which past medical history finding makes the client most at risk for this disease? Meningitis or encephalitis during the last 5 years Seizures or trauma to the brain within the last year Back injury or trauma to the spinal cord during the last 2 years Respiratory or gastrointestinal infection during the previous month
Respiratory or gastrointestinal infection during the previous month
A patient with a decreased LOC and an absent gag reflex was just admitted to the neurologic unit. In what position should the nurse place the patient? Prone Head of bed should be elevated 45 to 90 degrees Flat Side lying with head of bed elevated 10 to 30 degrees
Side lying w/HOB elevated 10 to 30 degrees
The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? Speak loudly but mumble or slur the words Speak loudly and clearly while facing the client Speak at a normal tone and pitch, slowly and clearly Speak loudly and directly into the client's affected ear
Speak at a normal tone and pitch, slowly and clearly
The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? Speak loudly Speak frequently Speak at a normal volume Speak directly into the impaired ear
Speak at a normal volume
The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? Taking medications as scheduled Eating large, well-balanced meals Doing muscle-strengthening exercises Doing all chores early in the day while less fatigued
Taking medications as scheduled
A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication? Sodium level, 140 Uric acid level, 4.0 WBC, 3000 BUN, 10
WBC, 3000
The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? "Alcohol is not contraindicated while taking this medication" "Good oral hygiene is needed, including brushing and flossing" "The medication dose may be self-adjusted, depending on side effects" "The morning dose of the medication should be taken before serum medication level is drawn"
"Good oral hygiene is needed, including brushing and flossing"
When the nurse is gathering a history from a patient newly diagnosed with glaucoma, the patient reports the following statement to the nurse. Which statement would be consistent with the patient's diagnosis? "I began seeing halos around lights and had dim vision." "I had a difficult time matching my blue socks." "My eyes began to tear and itch." "I could see the street signs better than my hand."
"I began seeing halos around lights and had dim vision."
The nurse is caring for a newly admitted older adult in a skilled care facility. Which statement(s) by the client is/are most concerning? Select all that apply. "I don't remember what I ate for breakfast." "I don't think I'll enjoy being here." "My cat 'Mustang' is my baby." "Did my daughter bring my glasses?" "I'm in the emergency room."
"I don't remember what I ate for breakfast." "I'm in the emergency room."
What information from a health history collected from a 70-year-old should be further evaluated as a sign of presbycusis? "I haven't been going out with friends." "I am a retired truck driver." "My hobby is caring for livestock." "I watch television in the evening with my wife."
"I haven't been going out with friends."
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? "I can sit down to put on my pants and shoes" "I try to exercise every day and rest when I'm tired" "My son removed all loose rugs from my bedroom" "I don't need to use my walker to get to the bathroom"
"I don't need to use my walker to get to the bathroom"
A 45-year-old man reports that he is experiencing trouble with close vision that is becoming progressively worse. The nurse explains the reason for the problem. What statement shows that the patient understands the explanation? "This is a sign that I might have hypertension." "I might be having early signs of presbyopia." "So you think I might have had some kind of eye trauma?" "Which one of my medications caused this?"
"I might be having early signs of presbyopia."
The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions? "I will use a straw for drinking" "I will drive only during the daytime" "I will be careful because the device alters balance" "I will wash the skin daily under the lamb's wool liner of the vest"
"I will drive only during the daytime"
Which statement by the patient diagnosed with viral conjunctivitis indicates that more teaching is necessary? "I will wash my hands frequently." "I will use a washcloth to clean both my eyes, starting with the infected eye and moving to the uninfected eye." "I will avoid contact with other people until my symptoms are gone." "I will discard any leftover eye medication when the infection is gone."
"I will use a washcloth to clean both my eyes, starting with the infected eye and moving to the uninfected eye."
The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs reinforcement of information if the client makes which of the following statements? "I will wash my face with cotton pads." "I'll have to start chewing on the unaffected side." "I'll try to eat my food either very warm or very cold." "I should rinse my mouth sometimes if toothbrushing is painful."
"I'll try to eat my food either very warm or very cold."
During preoperative teaching, the 25-year-old patient receiving cochlear implants states, "I will be able to fully regain my hearing with the implants." What is the nurse's best response to the patient? "The implants will assist you to detect medium to loud environmental sound and conversation rather than restoring normal hearing." "The implant will assist you to restore normal hearing fully." "The implants will be immediately effective." "The implant will require minimal rehabilitation in order for you to recognize sounds."
"The implants will assist you to detect medium to loud environmental sound and conversation rather than restoring normal hearing."
A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? "The medication will help dilate the eye to prevent pressure from occuring" "The medication will relax the muscles of the eyes and prevent blurred vision" "The medication causes the pupil to constrict and will lower the pressure in the eye" "The medication will help block the responses that are sent to the muscles in the eye"
"The medication causes the pupil to constrict and will lower the pressure in the eye"
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? "We need to discourage him from wearing eyeglasses" "We need to place objects in his impaired field of vision" "We need to approach him from the impaired field of vision" "We need to remind him to turn his head to scan the lost visual field"
"We need to remind him to turn his head to scan the lost visual field"
A client who has GB asks, "Will I ever get better?" Which response would be the most appropriate answer by the nurse? "You'll notice your strength will improve each day." "We are doing everything we can to provide the best care." "You seem concerned about getting better. What do you think?" "Your chances for recovery are very good, but recovery is slow."
"Your chances for recovery are very good, but recovery is slow."
A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel, and a hyphema is diagnosed. The nurse should place the client in which position? Flat in bed A semi-Fowler's position Lateral on the affected side Lateral on the unaffected side
A semi-Fowler's position
The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem? Total loss of vision Pain in the affected eye A yellow discoloration of the sclera A sense of a curtain falling across the field of vision
A sense of a curtain falling across the field of vision
Which interventions should the nurse's plan of care include to help prevent autonomic dysreflexia in a patient with SCI? Select all that apply. Check for fecal impactions. Monitor blood pressure for hypotension. Check the urinary drainage system for any obstruction. Monitor bowel movements. Instruct the patient to wear a medic alert bracelet.
Check the urinary drainage system for any obstruction Monitor bowel movements
The nurse caring for the patient with Ménière disease restricts the following foods in the dietary plan. Select all that apply. Coffee Wine Baked potato Cheese Milk
Coffee Wine
The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? Gets angry with family if they interrupt task Experiences bouts of depression and irritability Has difficulty with using modified feeding utensils Consistently uses adaptive equipment in dressing self
Consistently uses adaptive equipment in dressing self
In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 9:00 a.m. for surgery that is scheduled for 9:15 a.m. What initial action should the nurse take in relation to the characteristics of the medication action? Provide lubrication to the operative eye prior to giving eye drops Call the surgeon, as this medication will further constrict the operative pupil Consult the surgeon, as there is not sufficient time for the dilative effects to occur Give the medication as prescribed; the surgeon needs optimal constriction of the pupil
Consult the surgeon, as there is not sufficient time for the dilative effects to occur
A 73-year-old patient has been diagnosed with ischemic stroke following diagnostic studies. Which medication must be given within a 4.5-hour window of symptom onset to be effective in lysing a clot? Heparin Coumadin Plavix Alteplase
Alteplase
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? Diplopia Eye pain Floating spots Blurred vision
Blurred vision
The nurse is caring for a baseball player who reports getting hit in the head with a baseball 1 hour prior to admission in the ED. What assessment requires immediate reporting? Eye pain Flashing lights in the visual field Headache, pain intensity rated as 2/10 Superficial head abrasion
Flashing lights in the visual field
The nurse assesses a patient who is complaining of an earache. What assessment finding would the nurse expect? Blue tympanic membrane Cerumen buildup Mastoid tenderness Tympanic retraction
Mastoid tenderness
The nurse enters the room of a client with advanced dementia to administer routine medications. The client becomes angry and agitated and throws a water cup at the nurse. What should the nurse do next? Clean up the water spill and leave the room Ask why the client is angry Call for another healthcare team member to come to the room Get another cup of water and try administering the pills agin
Call for another healthcare team member to come to the room
During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? Call the surgeon Reassure the client that this is normal Turn the client onto her or his operative side Administer the prescribed pain medication and antiemetic
Call the surgeon
A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications? Administer the eye drop first, followed by the eye ointment Administer the eye ointment first, followed by the eye drop Administer the eye drop, wait 15 minutes, and administer the eye ointment Administer the eye ointment, wait 15 minutes, and administer the eye drop
Administer the eye drop first, followed by the eye ointment
A patient is being evaluated for conductive versus sensorineural hearing loss. The nurse is performing the Rinne test. What result would the nurse expect to see if the patient has sensorineural hearing loss? Sound is heard equally in both ears. Air conduction is equal to bone conduction in the affected ear. Air conduction is longer than bone conduction in the affected ear. Air conduction is shorter than bone conduction in the affected ear.
Air conduction is longer than bone conduction in the affected ear.
The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? Cranial nerve I Cranial nerve IV Cranial nerve III Cranial nerve VII
Cranial nerve VII
The patient with significant visual impairment requires assistance with ADLs. The nurse provides support when serving food by performing which action? Leaving the tray on the patient's bedside table Serving hot food as quickly as possible Describing the food on the tray in terms of the face of a clock Ensuring all food is soft
Describing the food on the tray in terms of the face of a clock
A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication? Sodium level of 140 Platelet count of 400,000 Prothrombin time of 12 seconds Direct bilirubin level of 2
Direct bilirubin level of 2
A patient diagnosed with a stroke is experiencing slurred speech. The nurse would accurately document this finding as which clinical manifestation of stroke? Aphasia Dysphasia Dysarthria Apraxia
Dysarthria
The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? Nebulizer and pulse oximeter Blood pressure cuff and flashlight Nasal cannula and incentive spirometer Electrocardiographic monitoring electrodes and intubation tray
Electrocardiographic monitoring electrodes and intubation tray
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? Blowing the nose Isometric exercises Coughing vigorously Exhaling during repositioning
Exhaling during repositioning
The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? Avoid overuse of the eyes Decrease the amount of salt in the diet Eye medications will need to be administered for life Decrease fluid intake to control the intraocular pressure
Eye medications will need to be administered for life
The nurse is evaluating the neurological signs of a client in spinal shock following a spinal cord injury. Which observation indicates that spinal shock persists? Hyperreflexia Positive reflexes Flaccid paralysis Reflex emptying of the bladder
Flaccid paralysis
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? Fluid is clear and tests negative for glucose Fluid is grossly bloody in appearance and has a pH of 6 Fluid clumps together on dressing and has a pH of 7 Fluid separates into concentric rings and tests positive for glucose
Fluid separates into concentric rings and tests positive for glucose
Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? Pruritus Tachycardia Hypertension Impaired voluntary movements
Impaired voluntary movements
A patient sustained a C6 SCI 4 hours ago. What nursing diagnosis is a priority? Urinary retention Risk for impaired skin integrity Ineffective breathing pattern Powerlessness
Ineffective breathing pattern
A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. What action should the nurse implement based on this finding? Provide the client with materials on legal blindness Instruct the client that he or she may need glasses when driving Inform the client of where he or she can purchase a white can with a red tip Inform the client that it is best to sit near the back of the room when attending lectures
Instruct the client that he or she may need glasses when driving
A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action? Irrigate the eyes with water. Come to the emergency department. Call the health care provider (HCP). Irrigate the eyes with diluted hydrogen peroxide.
Irrigate the eyes with water
A client with spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Limiting bladder catheterization to once every 12 hours Turning and repositioning the client at least every 2 hours Ensuring that the client has a bowel movement at least once a week
Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Turning and repositioning the client at least every 2 hours
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. Loosening restrictive clothing Restraining the client's limbs Removing the pillow and raising padded side rails Positioning the client to the side, if possible, with the head flexed forward Keeping the curtain around the client and the room door open so when help arrives they can quickly enter the room
Loosening restrictive clothing Removing the pillow and raising padded side rails Positioning the client to the side, if possible, with the head flexed forward
A patient is scheduled for an EEG tomorrow. Which piece of information should the nurse provide to the patient prior to the procedure? Antiseizure medications need to be taken prior to procedure. Sedation will be given during the procedure. There is a slight chance of electric shock. Maintain a sleep-deprived state the night before the procedure.
Maintain a sleep-deprived state the night before the procedure.
The nurse is caring for a client with chronic back pain. Codeine has been prescribed for the client. Specific to this medication, which intervention should the nurse include in the plan of care while the client is taking this medication? Monitor radial pulse Monitor bowel activity Monitor apical heart rate Monitor peripheral pulses
Monitor bowel activity
Betaxolol hydrochloride (Betoptic SR) eye drops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side effects of this medication? Assessing for edema Monitoring temperature Monitoring blood pressure Assessing blood glucose level
Monitoring blood pressure
The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? Sternal rub Nailbed pressure Pressure on the orbital rim Squeezing of the sternocleidomastoid muscle
Nailbed pressure
What initial diagnostic test is recommended to assess for a cerebral bleed? MRI Noncontrast CT CT with contrast Cerebral angiography
Noncontrast CT
Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? Apply normal saline drops Note the time of day the test was done Contact the PHCP Instruct the client to sleep with the head of the bed flat
Note the time of day the test was done
The nurse is caring for a client following enucleation to treat an ocular tumor and notes the presence of bright red drainage on the dressing. Which action should the nurse take at this time? Document the finding Continue to monitor the drainage Notify the PHCP Mark the drainage on the dressing and monitor for any increase in bleeding
Notify the PHCP
The nurse knows that the signs and symptoms of meningeal irritation include which of the following? Select all that apply. Nuchal rigidity and headache Kernig and Brudzinski signs Aphasia and motor weakness Photophobia Ptosis
Nuchal rigidity and headache Kernig and Brudzinksi signs Photophobia
The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse should instruct the client to take which action? Eat before instilling the drops Swallow several times after instilling the drops Blink vigorously to encourage tearing after instilling the drops Occlude the nasolacrimal duct with a finger after instilling the drops
Occlude the nasolacrimal duct with a finger after instilling the drops
A patient taking aspirin for stroke prevention reports the development of hearing disturbances. The appropriate intervention is to decrease the dose in order to prevent which condition? Ototoxicity Vertigo Nystagmus Otitis externa
Ototoxicity
An older adult client is hospitalized with a lung infection and has been disorientated and confused since admission. Which cue(s) could be a reason(s) for the cognitive change? Select all that apply. Oxygen saturation level of 90% Administration of nephrotoxic antibiotics. Use of a bedtime sleeping pill. Temperature of 103.4 F Unfamiliar environment
Oxygen saturation level of 90% Use of a bedtime sleeping pill. Temperature of 103.4 F Unfamiliar environment
The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. Padding the side rails of the bed Placing an airway at the bedside Placing the bed in the high position Putting a padded tongue blade at the head of the bed Placing oxygen and suction equipment at the bedside Flushing the intravenous catheter to ensure that the site is patent
Padding the side rails of the bed Placing an airway at the bedside Placing oxygen and suction equipment at the bedside Flushing the intravenous catheter to ensure the site is patent
A patient arrives at a minor emergency center complaining of eye pain after an animal scratch incident. What would the nurse expect to find during the assessment? An injury to the opposite eye Pain while blinking Bleeding from the tear duct Change in distance vision
Pain while blinking
A military veteran is being seen at the clinic for what his wife calls "strange behaviors." Which behavior(s) is/are concerning? Select all that apply. Panic attacks with an impending sense of doom. Forgetfulness and leaving food cooking on the stove. Walking 4-5 times a day throughout the neighborhood. Hesitation and fear to use the city's public transportation. Spending hours at the shooting range, firing weapons.
Panic attacks with an impending sense of doom. Forgetfulness and leaving food cooking on the stove. Hesitation and fear to use the city's public transportation.
The nurse is completing a focused assessment to determine the cognitive mental status of an older adult with symptoms of acute hallucinations. Which action is the priority? Perform the assessment when the client is well-rested Reorient the client to time and place during the assessment Perform the assessment in a location without distracting stimuli Provide a sedative before the assessment to reduce anxiety
Perform the assessment in a location without distracting stimuli
A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? Apply an eye patch Perform visual acuity tests Irrigate the eye with sterile saline Remove the piece of wood using a sterile eye clamp
Perform visual acuity tests
The nurse is planning care for a client with dementia who is disorientated to location, day, and time. Physically the client is mobile and has a steady gait. Which priority action should the nurse include? Reorient the client frequently Place suction at the bedside in case of aspiration Determine the client's code status with the family Place a bed alarm
Place a bed alarm
The nurse is assisting with a lumbar puncture. What is the most common complication for which the nurse should monitor the patient following the procedure? Post-lumbar puncture headache Herniation of intracranial contents Spinal epidural abscess Meningitis
Post-lumbar puncture headache
A patient with a brain tumor is receiving palliative care. What does the nurse understand to be true about palliative care? Select all that apply. Providing comfort care Early identification of spiritual needs to the patient Management of symptoms Does not include pain management Is not an option with a patient with a brain tumor
Providing comfort care Early identification of spiritual needs to the patient Management of symptoms
A client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? Giving client full control over care decisions and restricting visitors Providing positive feedback and encouraging relaxation Providing information, giving positive feedback, and encouraging relaxation Providing intravenously administered sedatives, reducing distractions, and limiting visitors
Providing information, giving positive feedback, and encouraging relaxation
While assessing a client with Parkinson disease, the nurse identifies bradykinesia when the client exhibits which symptom? Muscle flaccidity An intention tremor Paralysis of the limbs Slow spontaneous movement
Slow spontaneous movement
A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of the laboratory result? Hypotension Tachycardia Slurred speech No abnormal finding
Slurred speech *Therapeutic level is 10-20 mcg/mL*
The nurse assesses the LOC of a patient who suffered a head injury and determines that the patient's GCS score is 15. Which of the following responses did the nurse assess to determine the GCS score? Select all that apply. Spontaneous eye opening Tachycardia, hypotension, bradycardia Ability to follow commands Unequal pupil size Orientation to person, place, and time
Spontaneous eye opening Ability to follow commands Orientation to person, place and time
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. The client is aphasic The client has weakness on the right side of the body The client has complete bilateral paralysis of the arms and legs The client has weakness on the right side of the face and tongue The client has lost the ability to move the right arm but is able to walk independently The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance
The client is aphasic The client has weakness on the right side of the body The client has weakness on the right side of the face and tongue
The nurse is preparing to test the visual acuity of a client, using the Snellen chart. Which identifies the accurate procedure for the visual acuity test? The right eye is tested, followed by the left eye, and then both eyes are tested Both eyes are assessed together, followed by an assessment of the right eye and then the left eye The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision
The right eye is tested, followed by the left eye, and then both eyes are tested
The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pill. Which information should the nurse include in the teaching plan? Pregnancy must be avoided while taking phenytoin The client may stop the medication if it is causing severe gastrointestinal effects There is a potential of decreased effectiveness of birth control pills while taking phenytoin There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together
There is a potential of decreased effectiveness of birth control pills while taking phenytoin
A client is diagnosed with a problem involving the inner ear. Which is the most common client complaint associated with a problem involving this part of the ear? Pruritus Tinnitus Hearing loss Burning in the ear
Tinnitus
The client arrives at the emergency department complaining of back spasms. The client states, "I have been taking 2 to 3 aspirin every 4 hours for the last week, and it hasn't helped my back." Since acetylsalicylic acid intoxication is suspected, the nurse should assess the client for which manifestation? Tinnitus Diarrhea Constipation Photosensitivity
Tinnitus
Meperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse monitor for? Select all that apply. Diarrhea Tremors Drowsiness Hypotension Urinary frequency Increased respiratory rate
Tremors Drowsiness Hypotension
The nurse is testing the cranial nerves of a patient diagnosed with myasthenia gravis. The nurse asks the patient to clench his jaw while she palpates the temporal and masseter muscles. The nurse is correctly testing which cranial nerve? Abducens Trigeminal Acoustic Hypoglossal
Trigeminal
What is the most common initial symptom that a nurse might expect a client with MS to complain about? Diarrhea Headaches Skin infections Visual disturbances
Visual disturbances
The nurse prepares a client for ear irrigation as prescribed by the primary health care provider. Which action should the nurse take when performing the procedure? Warm the irrigating solution to 98.6 F (37.0 C) Position the client with the affected side up following the irrigation Direct a slow, steady stream of irrigation solution toward the eardrum Assist the client to turn her or his head so that the ear to be irrigated is facing upward
Warm the irrigating solution to 98.6 F (37.0 C)
The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. Wash hands Put gloves on Place the drop in the conjunctival sac Pull the lower lid down against the cheekbone Instruct the client to squeeze the eyes shut after instilling the eye drop Instruct the client to tilt the head forward, open the eyes, and look down
Wash hands Put gloves on Place the drop in the conjunctival sac Pull the lower lid down against the cheekbone
