Study Guide Exam 1

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke?

"Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

The nurse determines that the client needs further instruction about prescribed thyroid replacement medication if which statement is made?

"I would expect full therapeutic effect from the medication within 3 to 5 days."

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next?

. Administer IV calcium gluconate.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area?

1.The left side of the body

Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program?

A. Hypertension

Which assessment finding would be the EARLIEST and MOST sensitive indicator that there is an alteration in intracranial regulation?

A. change in level of consciousness

A client arrives at the clinic complaining of fatigue, lack of energy, constipation, and depression. Hypothyroidism is diagnosed, and levothyroxine is prescribed. What is an expected outcome of the medication?

Achieves normal thyroid hormone levels

The nurse is developing a plan of care for a newborn infant with spina bifida (meningomyelocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure (ICP). Which assessment technique should be performed to detect the presence of an increase in ICP?

Assessing the anterior fontanel for bulging

The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the appropriate nursing intervention?

Assist the client to eat with the left hand to build strength.

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)?

C. Slow and possibly fearful performance of tasks.

A patient is recovering from a thyroidectomy. The patient starts to complain of tingling and numbness in the face, toes, and fingers. Which of the following findings below warrants attention?*

Ca+ level: 6 mg/dL

The nurse is caring for a patient scheduled for a computed tomography (CT) scan with contrast. What should be included in pre-procedure preparation? (Select all that apply.)

Check blood urea nitrogen (BUN) and creatinine levels. Question the patient about allergies to dye, shellfish, or iodine. Explain to the patient that a sensation of warmth may be felt when dye is injected. Tell the patient to report any nausea, itchiness, or difficulty breathing during the scan.

The nurse is caring for a patient given alteplase following a stroke. Which assessment finding is the highest priority to report to the primary health care provider?

Client's blood pressure is 194/120

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP?

Confusion

The client has received a contrast medium. Which teaching will the nurse provide to avoid any neurologic health problems after the procedure?

Drink at least 1000 to 1500ml of water today

The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding would the nurse expect to note in this client?

Dry skin

A client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which of the following activities?

Exhaling during repositioning

A nurse assesses a client with a brain tumor. Which newly identified assessment findings would alert the nurse to urgently communicate with the primary health care provider? (Select all that apply.)

Glasgow Coma Scale score of 8 Decerebrate posturing Decreasing level of consciousness

Factors that contribute to neurologic changes in the older adult

Gradual slowing of ability to learn new information. - Gradual decline in some motor behaviors. - Muscle atrophy. - Decrease in the number of functional motor units. - Increase in motor unit amplitude. - Decrease in motor nerve conduction velocities. - Decrease in proportion of fast-twitch muscle fibers.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific primary health care provider prescriptions, the nurse would place the client in which positions? Select all that apply.

Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees

A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction?

Hold your cane on the right side.

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply.

Hyperoxygenating before suctioning Maintaining the head and neck in midline position Maintaining the head of the bed (HOB) at 30 degrees elevation

The nurse is caring for a client with increased intracranial pressure as a result of head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

Members of the family of an unconscious client with increased intracranial pressure from a head injury are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation?

It is possible the client can hear the family.

A client is admitted to the emergency department and a diagnosis of myxedema coma is made. Which action would the nurse plan to carry out initially?

Maintain a patent airway

The nurse is evaluating the use of a cane for a client who sustained a stroke who has residual left-sided weakness. The nurse would intervene and correct the client if the nurse observed that the client performs which action?

Moves the cane when the right leg is moved

The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse would assess the child frequently for which early sign of increased ICP?

Nausea

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse would use which technique to test the client's peripheral response to pain?

Pressure on the nail beds

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?

Respiratory distress

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient?

Support weight on stronger leg and cane and advance weaker foot forward.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record?

The client experienced paresthesias a few days before admission to the hospital.

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?

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 caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose?

To treat hypocalcemic tetany

The nurse is providing instructions to an assistive personnel (AP) who is assigned to care for a client who had a brain attack (stroke) and is experiencing hemiparesis of the right arm and leg. Where would the nurse instruct the AP to place personal articles for morning care?

Within the client's reach on the left side

The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.)

a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain an SaO2 of 95% or greater. e. Avoid clustering care nursing activities and procedures.

The nurse is developing a plan of care for a client who is scheduled for a thyroidectomy. The nurse focuses on psychosocial needs, knowing that which is likely to occur in the client?

body image changes

A nurse is providing education for a patient beginning thyroid replacement therapy for hypothyroidism. Which information provided by the nurse to the patient is most important?

d. In most cases, treatment is likely to be lifelong.

Review why phenytoin would be given to someone with a brain tumor

phenytoin is an anti-epileptic/anti-seizure medication (dilantin) Brain tumor/surgery can cause elevated ICP and therefore seizures.