Unit 5 - 3rd Semester
A 2½-year-old boy who has undergone surgery to revise a ventriculoperitoneal shunt is to be discharged. The nurse advises the parents to call the clinic if the child does what? A) Appears drowsy after a nap and becomes irritable B) Talks incessantly regardless of the presence of others C) Becomes angry when frustrated and has a temper tantrum D) Starts arguments with playmates, claiming that their toys are the child's
A
A client is admitted to the emergency department in the midst of persistent tonic-clonic seizures (status epilepticus). Diazepam is to be administered immediately. In addition to decreasing central neuronal activity, what other effect does the nurse anticipate? A) Relaxing peripheral muscles B) Slowing cardiac contractions C) Dilating tracheobronchial structures D) Providing amnesia of the convulsive episode
A
A client with early-stage AD is admitted to the surgical unit for biopsy. Which client problem is the priority? A) Potential for injury r/t chronic confusion and physical deficits B) Risk for reduced mobility r/t progression of disability C) Potential for skin breakdown r/t immobility and/or impaired nutritional status D) Lack of social contact r/t personality and behavior changes
A
A mother reports that her child has episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure? a. Absence b. Atonic c. Tonic-clonic d. Simple partial
A
A nurse is admitting a client with the diagnosis of dementia. What should the nurse ask the client to best assess orientation to place? A) "Where are you?" B) "Who brought you here?" C) "Do you know where you are?" D) "Do you know what day you arrived?"
A
A patient who has epilepsy will begin an anticonvulsant medication. The patient asks the nurse how long the medication will be necessary. How will the nurse respond? a. The medication is usually taken for a lifetime. b. The medication will be given until you are seizure-free. c. You will need to take the medication for 3 to 5 years. d. You will take the medication as needed for seizure activity.
A
In caring for a child with a compound fracture, the nurse should carefully assess for a. Infection b. Osteoarthritis c. Epiphyseal disruption d. Periosteum thickening
A
In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? A. Allow extra time with feedings. B. Assign different personnel to the newborn each day. C. Place the newborn in a well-lit room. D. Monitor for hyperthermia.
A
Spinal fusion is performed in an adolescent with scoliosis. What postoperative nursing intervention is specifically related to surgery for scoliosis? A. Log-rolling every 2 hours B. Checking the dressing frequently C. Supervising deep-breathing exercises D. Maintaining the adolescent in the supine position for 3 days
A
The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? A. Absence B. Myoclonic C. Simple partial D. Tonic
A
The spouse of the client with Alzheimer's disease is listening to the hospice nurse explaining the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." B. "Memantine (Namenda) is indicated for treatment of early symptoms of Alzheimer's disease. C. "Rivastigmine (Exelon) is used to treat depression." D. "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."
A
What is the most appropriate intervention for an adolescent with a mild scoliosis? a. Long-term monitoring b. Surgical intervention c. Bracing d. No follow-up
A
When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with observable distended scalp veins, the nurse recognizes these signs as indicative of a. Hydrocephalus b. Syndrome of inappropriate antidiuretic hormone (SIADH) c. Cerebral palsy d. Reyes syndrome
A
Which information should the nurse give to a child who is to have magnetic resonance imaging (MRI) of the brain? a. Your head will be restrained during the procedure. b. You will have to drink a special fluid before the test. c. You will have to lie flat after the test is finished. d. You will have electrodes placed on your head with glue.
A
Which question, during a hospital admission assessment, best indicates that the nurse understands the needs of a child with Down Syndrome? A) "Can you go over her daily routine with me?" B) "Does she require a special diet?" C) "Does she sleep through the night?" D) "Is she toilet trained?"
A
Which statement by the mother of an adolescent being discharged after spinal fusion for severe scoliosis indicates the need for further teaching? a. I am glad we chose surgery. Now it is all over and done. b. Ill see you in a month; well be back fairly regularly. c. I have to pick up some more T-shirts on the way home. d. Those exercises the physical therapist showed us were not too hard.
A
You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature? A. Rectal B. Oral C. Axillary
A
The nurse is caring for a child who sustained a head injury from a fall. The nurse should perform which actions in the care of the child? Select all that apply. A) Restrict oral fluid intake. B) Elevate the head of the bed. C) Perform neurological assessments. D) Encourage coughing and deep breathing. E) Place the child in a flat position during sleep.
A, B, C
The home care nurse is assigned to visit a Mexican American client to perform an admission assessment. On initially meeting the client, which actions would be considered culturally appropriate? Select all that apply. A) Touch the client B) Greet the client with a handshake C) Smile during the admission assessment D) Use affirmative nods during conversations E) Use humor throughout the admission assessment
A, B, C, D
Tissue ischemia and nerve damage are serious complications that may result from immobilization in a cast or from traction. The five Ps of vascular impairment can be used as a guide when assessing for neurovascular problems. List the five Ps. A) Pain B) Pallor C) Pulselessness D) Physiology E) Paresthesia F) Paralysis
A, B, C, E, F
A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.) a. Sodium level b. Liver enzymes c. Clotting factors d. Cardiac enzymes e. Creatinine level
A, C
The nurse should take which actions when caring for a child experiencing a seizure? Select all that apply. A) Place the child on the side. B) Restrain the child to prevent head trauma. C) Ease the child who is sitting in a wheelchair onto the floor. D) Pull the teeth apart and place an oral airway into the child's mouth. E) Offer the child a sip of water to elicit the swallowing reflex and prevent aspiration.
A, C
What are the risk factors for developing Alzheimer's Disease? Select all that apply. A) Women B) Hypotension C) Hypertension D) History of TBI E) Down Syndrome F) Anorexia
A, C, D, E
A patient who is having a tonic-clonic seizure is prescribed Phenobarbital. During administration of this drug, it is important the nurse monitors for: Select all that apply: A. Respiratory depression B. Hypertension C. Disseminated intravascular clotting D. Hypotension E. Fever
A, D
A 13-year-old girl is found to have idiopathic scoliosis. She is upset about the treatment regimen and is worried about being different from her friends. What should the nurse do to help the child maintain a positive self-image during treatment? A. Remind her how crooked her back will be if she refuses treatment. B. Help her investigate appropriate clothing to enhance her appearance. C. Disregard her negative characteristics and focus on her positive attributes. D. Refer her for psychological counseling until the treatment program is completed.
B
A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. These findings are most suggestive of: a. Microcephaly b. Down syndrome c. Cerebral palsy d. Fragile X syndrome
B
A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure
B
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)
B
A patient with a history of epilepsy is taking Phenytoin. The patient's morning labs are back, and the patient's Phenytoin level is 7 mcg/mL. Based on this finding, the nurse will? A. Assess the patient for a rash B. Initiate seizure precautions C. Hold the next dose of Phenytoin D. Continue to monitor the patient
B
A school nurse is screening children for scoliosis. In what age group is it usually identified? A) Adolescence B) Preadolescence C) Early school years D) Middle school years
B
After a tonic-clonic seizure, it would not be unusual for a child to display a. Irritability and hunger b. Lethargy and confusion c. Nausea and vomiting d. Nervousness and excitability
B
This type of cerebral palsy is marked by involuntary, uncoordinated motion with varying degrees of muscle tension. Children with this disorder are constantly in motion and the whole body is in a state of slow, writhing muscle contractions whenever voluntary movement is attempted. Hearing loss is most common in this group. A) Ataxia B) Dyskinetic C) Spastic D) Rigid
B
A nurse is determining which tasks to delegate. Which actions should a registered nurse perform while caring for a client in traction? Select all that apply. A) Padding traction connections B) Determining correct body alignment C) Assessing complications associated with immobility D) Teaching the client about range-of-motion (ROM) exercises E) Assisting the client with passive and active range-of-motion (ROM) exercises
B, C, D
The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? (Select all that apply.) A. Alopecia B. Headaches C. Dizziness D. Diplopia E. Increased blood glucose
B, C, D
What are some Basic Activities of Daily Living (BADLs)? Select All That Apply. A) Managing money B) Eating C) Hygiene D) Dressing E) Cleaning
B, C, D
A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching? a. I should expect my child to have a few episodes of vomiting. b. If I notice sleep disturbances, I should contact the physician immediately. c. I should expect my child to have some behavioral changes after the accident. d. If I notice diplopia, I will have my child rest for 1 hour.
C
A nurse delegates care for a client with early-stage Alzheimers disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care? a. If she is confused, play along and pretend that everything is okay. b. Remove the clock from her room so that she doesnt get confused. c. Reorient the client to the day, time, and environment with each contact. d. Use validation therapy to recognize and acknowledge the clients concerns.
C
A patient is taking Rivastigmine. The nurse should teach the patient and family which information about Rivastigmine? A) Hepatotoxicity may occur B) The initial dose is 6 mg three times a day C) GI distress is a common side effect D) Weight gain may be a side effect
C
In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: a. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. b. Two thirds of newborns with fetal alcohol syndrome (FAS) are boys. c. Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. d. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.
C
The nurse is assessing an older adult patient with AD using the Mini-Mental State Examination. What does this exam measure? A) Level of intelligence B) Functional ability C) Severity of cognitive impairment D) Alterations in communication
C
Throughout their life span, cognitively impaired children are less capable of managing environmental challenges and are at risk for a. Nutritional deficits b. Visual impairments c. Physical injuries d. Psychiatric problems
C
Which Functional Test targets engagement in life activities for children 2-12 years with physical disabilities? A) GCS B) Functional Activities Questionnaire (FAQ) C) Now, Growth & Development, Activities of Daily Living, General Health, Environment, and Documentation (NGAGED) D) Mini-Mental Status Examination (MMSE)
C
Which behavior indicates that the treatment plan for a child diagnosed with autism spectrum disorder was effective? The child: a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parents hand while walking. d. spins around and claps hands while walking.
C
Which patient below with ICP is experiencing Cushing's Triad? A patient with the following: A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12
C
A 13-year-old adolescent is found to have idiopathic scoliosis. Because exercise and avoidance of fatigue are essential components of care, which sport should the nurse suggest as the most therapeutic for this pre-adolescent? A) Wrestling B) Bowling C) Golf D) Swimming
D
A 4½-year-old child is brought to the emergency department with a fractured tibia. Which type of fracture is most common in children of this age? A) Transverse B) Comminuted C) Compound D) Greenstick
D
A boy who has fractured his forearm is unable to extend his fingers. The nurse knows that this: A) May indicate damage to epiphyseal plate B) Is normal following this type of injury C) May indicate fat embolism D) May indicate compartment syndrome
D
A child is brought to the emergency department in generalized tonic-clonic status epilepticus. Which medication should the nurse expect to be given initially in this situation? a. Clorazepate dipotassium (Tranxene) b. Fosphenytoin (Cerebyx) c. Phenobarbital d. Lorazepam (Ativan)
D
A client with a brain attack (cerebrovascular accident) is admitted to the hospital. What is the priority nursing intervention for this client? A) Changing position every two hours B) Keeping a serial record of the pulse C) Performing range-of-motion exercises D) Monitoring for increased intracranial pressure
D
A client with a diagnosis of dementia of the Alzheimer type has been taking donepezil 10 mg/day for 3 months. The client's partner calls the clinic and reports that the client has increasing restlessness and agitation accompanied by nausea. What does the nurse advise the partner to do? A) Give the medication with food. B) Administer the medication to the partner at bedtime. C) Omit one dose today and start with a lower dose tomorrow. D) Bring the partner to the clinic for testing and a physical examination
D
A clinical manifestation of Down Syndrome is: A) Extremely soft and smooth skin B) Hypertonicity of large muscles C) Long, narrow face with large ears D) Single transverse palmar crease
D
A mother brings her infant to the ED and says he had a seizure. While a nurse is obtaining a history, the mother says she was running out of formula so she stretched the formula by adding 3 times the normal amount of water. Electrolytes and BG levels are drawn on the infant. The nurse should expect which laboratory value? A) BG = 120 mg/dl B) Chloride = 104 mol/L C) Potassium = 4 mol/L D) Sodium = 125 mol/L
D
Aphasia in Alzheimer's is defined as: A) Loss of sensory comprehension, faces and sounds B) Impaired memory C) Inability to use words/objects correctly D) Inability to speak or understand
D
Components of the GCS the nurse would use to assess a patient after a head injury include A) blood pressure. B) cranial nerve function. C) head circumference. D) verbal responsiveness.
D
During a generalized tonic-clonic seizure, the young adult patient becomes cyanotic. What should the nurse do FIRST? A) Raise the HOB and apply NC oxygen B) Call the provider and obtain the equipment to intubate C) Suction the patient and alert the Rapid Response Team D) Stay with the patient because cyanosis is usually self-limiting
D
How should the nurse explain positioning for a lumbar puncture to a 5-year-old child? a. You will be on your knees with your head down on the table. b. You will be able to sit up with your chin against your chest. c. You will be on your side with the head of your bed slightly raised. d. You will lie on your side and bend your knees so that they touch your chin.
D
Many of the physical characteristics of Down syndrome present feeding problems. Care of the infant should include: a. Delaying feeding solid foods until the tongue thrust has stopped b. Modifying diet as necessary to minimize the diarrhea that often occurs c. Providing calories appropriate to childs age d. Using special bottles that may assist the infant with feeding
D
Patient and parent education for the child who has a synthetic cast should include a. Applying a heating pad to the cast if the child has swelling in the affected extremity b. Wrapping the outer surface of the cast with an Ace bandage c. Splitting the cast if the child complains of numbness or pain d. Covering the cast with plastic and waterproof tape to keep it dry while bathing or showering
D
The nurse is providing teaching to the parents of a 5-year-old child who will begin taking phenytoin (Dilantin). What information will the nurse include when teaching these parents about their childs medication? a. Drug interactions are uncommon with phenytoin. b. There are very few side effects associated with this drug. c. The therapeutic range of phenytoin is between 15 and 30 mcg/mL. d. Your child may need a higher dose than expected.
D
When a child with a musculoskeletal injury on the foot is assessed, what is most indicative of a fracture? a. Increased swelling after the injury is iced b. The presence of localized tenderness distal to the site c. The presence of an elevated temperature for 24 hours d. The inability of the child to bear weight
D
What are the areas to assess when caring for a child with Down Syndrome? Select all that apply. A) Typical coping patterns B) Daily Routines C) Understanding of language D) Learning abilities E) Social and Motor skills F) All of the above
F
A nurse is teaching a high school student about scoliosis treatment options. On what should the nurse focus? A. Effect on body image B. Least invasive treatment C. Continuation with schooling D. Maintenance of contact with peers
A
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask? a. Do you live in a crowded residence? b. When was your last tetanus vaccination? c. Have you had any viral infections recently? d. Have you traveled out of the country in the last month?
A
A nurse witnesses a client with late-stage Alzheimers disease eat breakfast. Afterward the client states, I am hungry and want breakfast. How should the nurse respond? a. I see you are still hungry. I will get you some toast. b. You ate your breakfast 30 minutes ago. c. It appears you are confused this morning. d. Your family will be here soon. Lets get you dressed.
A
A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Promote the use of the patients sense of humor by telling jokes.
A
A patient is taking Phenytoin for treatment of seizures. Which statement by the patient requires you to re-educate the patient about this medication? A. "Every morning I take this medication with a full glass of milk with my breakfast." B. "I know it is important to have my drug levels checked regularly." C. "I will report a skin rash immediately to my doctor." D. "This medication can lower my body's ability to clot and fight infection."
A
A patient who is independent in ADLs, forgets names, has short-term memory loss, and has mild impaired cognition is associated with what stage of Alzheimer's Disease? A) Early (Mild, Stage 1) B) Middle (Moderate, Stage 2) C) Late (Severe, Stage 3)
A
A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol b. Cocaine c. Heroin d. Marijuana
A
A priority nursing intervention when caring for a child in a Pavlik harness is a. Skin care b. Bowel function c. Feeding patterns d. Respiratory function
A
A young adult who is unconscious after an accident is brought to the emergency department. The client's pupils are equal and responsive to light. As part of the neurologic assessment, the nurse applies a painful stimulus to the client's left lower leg. Which is an expected response in a healthy adult? A) Withdrawing the leg B) Making no movement C) Plantar flexing the left foot D) Flexing the upper extremities
A
Agnosia in Alzheimer's is defined as: A) Loss of sensory comprehension, faces and sounds B) Inability to speak or understand C) Inability to use words/objects correctly D) Impaired memory
A
Parents have learned that their 6-year-old child has autism. The nurse may help the parents to cope by explaining that the child may a. Have an extremely developed skill in a particular area b. Outgrow the condition by early adulthood c. Have average social skills d. Have age-appropriate language skills
A
The home health nurse reads in the patient's chart that the patient has AD and is demonstrating apraxia. Which patient behavior supports this documentation? A) Pushes at the food on her plate with her eyeglasses B) Is unable to understand or follow simple command C) Sustains a burn from a heating pad, without realizing it D) Says she can't remember the name of her dog
A
The nurse at a health care clinic is preparing to examine a Hispanic child who was brought to the clinic by the mother. During assessment of the child, the nurse should avoid which action? A) Overly admiring the child B) Taking the child's temperature C) Obtaining an interpreter if necessary D) Asking the mother questions about the child
A
The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take? A) Assess the client's airway. B) Place pads on the side rails. C) Notify the healthcare provider. D) Leave and obtain the crash cart.
A
The nurse is caring for a client with advanced AD. Which communication technique is best to use with this client? A) Assuming that they client is not totally confused B) Providing the client with several options to choose from C) Waiting for the client to express a need D) Writing down instructions for the client
A
The nurse is preparing to assist with blood collection on a newly admitted patient who has been taking phenytoin for several years. The provider has ordered a complete blood count and liver function tests. Which other blood test will the nurse discuss with the provider? a. Blood glucose b. Coagulation studies c. Renal function tests d. Serum electrolytes
A
The nurse is providing teaching for the family of a patient who has been newly diagnosed with Alzheimers disease (AD). Which statement by the family member indicates understanding of the teaching? a. Alzheimers disease is a chronic, progressive condition. b. Alzheimers disease affects memory but not personality. c. The onset of Alzheimers disease is usually between 65 and 75 years. d. With proper treatment, symptoms of this disease can be arrested.
A
This type of cerebral palsy is characterized by loss of coordination, equilibrium. Patient presents to be "shaky" and "clumsy". This type of CP has a likely-hood for falls. A) Ataxia B) Dyskinetic C) Spastic D) Rigid
A
What is a sign of increased intracranial pressure (ICP) in a 10-year-old child? a. Headache b. Bulging fontanel c. Tachypnea d. Increase in head circumference
A
What should the nurse teach parents when the child is taking phenytoin (Dilantin) to control seizures? a. The child should use a soft toothbrush and floss the teeth after every meal. b. The child will require monitoring of renal function while taking this medication. c. Dilantin should be taken with food because it causes gastrointestinal distress. d. The medication can be stopped when the child has been seizure free for 1 month.
A
When caring for the patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes, A) hypertension, and bradycardia. B) hypertension, and tachycardia. C) hypotension, and bradycardia. D) hypotension, and tachycardia.
A
Which factor should the nurse include when teaching a parent about the care of a newborn in a Pavlik harness for hip dysplasia? A) The harness maintains the hips in flexion, abduction and external rotation B) The harness is worn continuously for 2 weeks C) The harness is only the first step of treatment D) The harness may be removed with every diaper change
A
Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of bacterial meningitis? a. CSF appears cloudy. b. CSF pressure is decreased. c. Few leukocytes are present. d. Glucose level is increased compared with blood.
A
You're assessing a patient who recently experienced a focal type seizure (partial seizure). As the nurse, you know that which statement by the patient indicates the patient may have experienced a focal impaired awareness (complex partial) seizure? A. "My friend reported that during the seizure I was staring off and rubbing my hands together, but I don't remember doing this." B. "I remember having vision changes, but it didn't last long." C. "I woke up on the floor with my mouth bleeding." D. "After the seizure I was very sleepy, and I had a headache for several hours."
A
A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease
A, B, C
A patient is taking Rivastigmine to improve cognitive function. What should the nurse teach the patient/family member to do? Select all that apply. A) Rise slowly to avoid dizziness B) Remove obstacles from pathways to avoid injury C) Closely follow the drug dosing schedule D) Have frequent checks for hypertension E) Receive regular liver function tests
A, B, C
A client in the early dementia stage of Alzheimer disease is admitted to a long-term care facility. Which activities must the nurse initiate? Select all that apply. A) Weighing the client once a week B) Having specialized rehabilitation equipment available C) Keeping the client in pajamas and robe most of the day D) Establishing a schedule with periods of rest after activities E) Reviewing the client's weekly budget and use of community resources F) Setting up a plan for weekly entertainment through a senior citizens group
A, B, D
A nurse should anticipate that which symptoms of Alzheimer disease will become apparent as the disease progresses from moderate to severe to late stage? Select all that apply. a. Agraphia b. Hyperorality c. Fine motor tremors d. Hypermetamorphosis e. Improvement of memory
A, B, D
A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? Select all that apply. A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees
A, B, D, E
You're assessing your patient load for the patients who are at MOST risk for seizures. Select all the patients below that are at risk: A. A 32-year-old with a blood glucose of 20 mg/dL. B. A 63-year-old whose CT scan shows an ischemic stroke. C. A 72-year-old who is post opt day 5 from open heart surgery. D. A 16-year-old with bacterial meningitis. E. A 58-year-old experiencing ETOH withdrawal.
A, B, D, E
A boy who has fractured his forearm is unable to extend his fingers. The nurse knows that this a. Is normal following this type of injury b. May indicate compartmental syndrome c. May indicate fat embolism d. May indicate damage to the epiphyseal plate
B
A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse? A) "Did you forget to take your medication?" B) "You are worried about having more seizures?" C) "You must be under a lot of stress right now." D) "Don't be too concerned because your medication needs to be increased."
B
A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? A) Nausea B) Lethargy C) Sunset eyes D) Hyperthermia
B
A client sustains a fractured right femur after an automobile accident and is admitted to the hospital's emergency department. Which assessment is the priority? A) Turn the client to the side-lying position. B) Take the client's pedal pulse in the affected extremity. C) Instruct the client to wiggle the toes of the right foot. D) Ask the client if numbness or tingling is present in the right foot.
B
A client with EARLY dementia asks the nurse to find her mother, who is deceased. What is the nurse's most appropriate response? A) We can call her in a little while if you want B) Your mother died over 20 years ago C) What did your mother look like? D) I'll ask your father to find her when he visits
B
A nurse cares for a client with advanced Alzheimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond? a. This is a sign of fatigue. The client would benefit from a daily nap. b. Engage the client in scheduled activities throughout the day. c. It sounds like this is difficult for you. I will consult the social worker. d. The provider can prescribe a mild sedative for restlessness.
B
The nurse is ordered to administer Lorazepam to a patient experiencing status epilepticus. As a precautionary measure, the nurse will also have what reversal agent on standby? A. Narcan B. Flumazenil C. Calcium Chloride D. Idarucizumab
B
When making rounds, a nurse observes a client who is experiencing a seizure. What should the nurse do? A) Hyperextend the client's neck B) Move obstacles away from the client C) Restrain the client's body movements D) Attempt to place an airway in the client's mouth
B
Which is the most effective way for a college student to minimize the risk for bacterial meningitis? A. Avoid large crowds. B. Get the meningococcal vaccine. C. Take a daily vitamin. D. Take prophylactic antibiotics
B
A 6-year-old patient who has been placed in skeletal traction has pain, edema, and fever. The nurse should suspect a. Meningitis b. Crepitus c. Osteomyelitis d. Osteochondrosis
C
The nurse is planning to instruct a Hispanic American client about nutrition and dietary restrictions. What factors should the nurse keep in mind when developing this client's plan of care? Select all that apply. A) They primarily eat raw fish B) They enjoy eating read meat C) They view food as a primary form of socialization D) Any occasion is seen as a time to celebrate with food E) They cook with food that lacks color, flavor, and texture
C, D
What are some Instrumental Activities of Daily Living (IADLs)? Select All That Apply. A) Toileting B) Bathing C) Managing money D) Using the phone E) Cooking
C, D, E
A patient diagnosed with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurses best reply? a. Your family member will never again be able to identify you. b. I think that is a question the health care provider should answer. c. One never knows. Consciousness fluctuates in persons with dementia. d. It is disappointing when someone you love no longer recognizes you.
D
A patient diagnosed with stage 2 Alzheimer disease calls the police saying, An intruder is in my home. Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as: a. hyperorality. b. aphasia. c. apraxia. d. agnosia.
D
A school-aged child with a seizure disorder has been taking carbamazepine for three years. What nursing intervention is most important to undertake regularly? A) Assessing the mouth for gingivitis B) Checking the pupillary reaction to light C) Keeping an accurate intake and output record D) Monitoring the child's complete blood cell counts
D
Amnesia in Alzheimer's is defined as: A) Loss of sensory comprehension, faces and sounds B) Inability to speak or understand C) Inability to use words/objects correctly D) Impaired memory
D
The best setting for daytime care for a 5-year-old autistic child whose mother works is a. Private day care b. Public school c. His own home with a sitter d. A specialized program that facilitates interaction by use of behavioral methods
D
The infant with Down syndrome is closely monitored during the first year of life for what serious condition? a. Thyroid complications b. Orthopedic malformations c. Dental malformation d. Cardiac abnormalities
D
A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes to painful stimuli, makes incomprehensible sounds, and flexes to pain. Using the Glasgow Coma Scale, which score will the nurse document in the client's medical record? A) 8 B) 9 C) 12 D) 15
A
A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A. Assessing neurologic status at least every 2 to 4 hours B. Decreasing environmental stimuli C. Managing pain through drug and nondrug methods D. Strict monitoring of hourly intake and output
A
A client who is receiving phenytoin to control a seizure disorder questions the nurse regarding this medication after discharge. How will the nurse respond? A) "Antiseizure drugs will probably be continued for life." B) "Phenytoin prevents any further occurrence of seizures." C) "This drug needs to be taken during periods of emotional stress." D) "Your antiseizure drug usually can be stopped after a year's absence of seizures."
A
A mother whose 7-year-old child has been placed in a cast for a fractured right arm reports that he will not stop crying even after taking acetaminophen with codeine. He also will not straighten the fingers on his right arm. The nurse tells the mother to a. Take him to the emergency department. b. Put ice on the injury. c. Avoid letting him get so tired. d. Wait another hour; if he is still crying, call back.
A
A nurse assessing a newborn elicits a positive response on the Ortolani test and as a result suspects that the newborn has developmental dysplasia of the hips (DDH). Which clinical finding supports this suspicion? A) Limited ability to abduct either hip B) Abduction of each hip to form a right angle C) Resistance to flexion of the hips D) Legs are of equal length
A
The nurse's friend fears that something is wrong with his grandmother saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? A) Have you taken her for a check-up? B) She has AD C) That is a normal part of aging D) You should look into respite care
A
The wife of a client with AD mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress? A) Arranges for respite care B) Provides positive reinforcement and support to the wife C) Restrains the client for a short time each day to allow the wife to rest D) Teaches the client improved self-care
A
You are the nurse assessing a 3-year-old child who has characteristics of autism. Which observed behaviors are associated with autism? Select all that apply. a. The child flicks the light in the examination room on and off repetitiously. b. The child has a flat affect. c. The child demonstrates imitation and gesturing skills. d. Mother reports the child has no interest in playing with other children. e. The child is able to make eye contact.
A, B, D
A child is in skeletal traction. Which interventions should the nurse implement to prevent complications of immobility? (Select All that Apply) A) Encourage coughing and deep breathing B) Reposition the child every 2 hours C) Limit fluid intake D) Avoid use of an egg-crate or sheepskin mattress E) Administer stool softeners as prescribed
A, B, E
A nurse is assessing a newborn for facial feature characteristics associated with fetal alcohol syndrome. Which characteristics should the nurse expect to assess? Select all that apply. a. Short palpebral fissures b. Smooth philtrum c. Low set ears d. Inner epicanthal folds e. Thin upper lip
A, B, E
The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply. A) Vomiting B) Irritability C) Hypotension D) Increased respirations E) Decreased level of consciousness
A, B, E
Which interventions should the nurse include in the home care instructions for the parents of a child who has a cast applied to the left forearm? Select all that apply. a. Keep small toys away from the cast. b. Use a padded ruler to scratch the skin under the cast if it itches. c. Daily assess the cast for unusual odors. d. Elevate the extremity on pillows for the first 24 to 48 hours. e. Numbness and tingling in the extremity is expected.
A, C, D
A 25 year-old female patient will begin taking phenytoin for epilepsy. The patient tells the nurse she is taking oral contraceptives (OCPs). Which response will the nurse give? a. Continue taking OCPs because phenytoin is not safe during pregnancy. b. You should use a backup method of contraception along with OCPs. c. You should stop taking OCPs because of drug-drug interactions with phenytoin. d. You should take low-dose aspirin while taking these medications to reduce your risk of stroke.
B
A child presents to the emergency department with complaints of fever, a petechial rash, nausea, vomiting, headache, and nuchal rigidity. What is the triage nurse's priority action? A) Administer acetaminophen for fever. B) Place the child on isolation precautions. C) Administer the meningococcal conjugate vaccination. D) Draw blood for a prescribed white blood cell (WBC) count.
B
A child with autism hospitalized with asthma. The nurse should plan care so that the a. Parents expectations are met. b. Childs routine habits and preferences are maintained. c. Child is supported through the autistic crisis. d. Parents need not be at the hospital.
B
A child with autism will display: A) Hyperkinetic behavior, poor coordination, and intellectual disabilities B) Absent or delayed speech and abnormal ways of relating to people C) Periods of remission and relapse D) Pubescent or adolescent onset of the disorder
B
A nurse is giving a parent information about autism. Which statement made by the parent indicates understanding of the teaching? a. Autism is characterized by periods of remission and exacerbation. b. The onset of autism usually occurs before 3 years of age. c. Children with autism have imitation and gesturing skills. d. Autism can be treated effectively with medication.
B
A patient who has impairment of all cognitive functions, demonstrates problems with handling money/finances, disoriented to time/place/event, increasingly dependent in ADLs, incontinent, and has episodes of wandering is associated with what stage of Alzheimer's Disease? A) Early (Mild, Stage 1) B) Middle (Moderate, Stage 2) C) Late (Severe, Stage 3)
B
An infant is found to have developmental dysplasia of the hip (DDH) 6 weeks after birth. The parents ask a nurse at the clinic why their infant must be restrained in a harness at such an early age. How should the nurse respond? A) Adduction devices cannot be used as effectively after the toddler age. B) Infants' hip joints are cartilaginous, allowing molding of the acetabulum. C) Infants are easier to manage in a harness than are toddlers. D) Mobility will be delayed if correction is postponed until later.
B
Developmental delays, self-injury, fecal smearing, and severe temper tantrums in a preschool child are symptoms of a. Down syndrome b. Intellectual disability c. Psychosocial deprivation d. Separation anxiety
B
The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)
B
The nurse is administering oral medication to a child with cerebral palsy who has compromised jaw control. Which method would facilitate administration of the liquid medication? A) Use a syringe to inject the medication into the back of the oropharynx. B) Place the fingers under the chin and the thumb on the cheek to open the jaw. C) Mix the medication with high fructose syrup and administer through a straw. D) Ask the child to pronounce the letter "o" while inserting the medication into the mouth.
B
The nurse is assessing a child who has just returned from surgery in a hip spica cast. Which outcome is the priority? A) The hips are adducted. B) Circulation is adequate. C) The child is on the right side. D) The head of the bed is elevated.
B
The nurse is assessing a patient who opens both eyes when spoken to, obeys commands, and seems confused during conversation. Which GCS will the nurse document? A) 15 B) 14 C) 11 D) 9
B
Three days after a cast is applied to a client's fractured tibia, the client reports that there is a burning pain over the ankle. The cast over the ankle feels warm to the touch, and the pain is not relieved when the client changes position. What is the nurse's priority action? A) Obtain a prescription for an antibiotic. B) Report the client's concern to the primary healthcare provider. C) Administer the prescribed medication for pain. D) Explain that this is typical after a cast is applied.
B
What finding should cause the nurse to suspect a diagnosis of spastic cerebral palsy? a. Tremulous movements at rest and with activity b. Sudden jerking movement caused by stimuli c. Writhing, uncontrolled, involuntary movements d. Clumsy, uncoordinated movements
B
What is the priority nursing care in the immediate postoperative period for a toddler with a newly applied hip spica cast? A) Offering oral fluids B) Checking the toddler's peripheral circulation C) Encouraging independent incentive spirometer use D) Teaching how to use the overhead trapeze
B
When assessing a 2-year-old diagnosed with autism spectrum disorder, a nurse expects: a. hyperactivity and attention deficits. b. failure to develop interpersonal skills. c. history of disobedience and destructive acts. d. high levels of anxiety when separated from a parent.
B
When assessing a child for an upper extremity fracture, the nurse should know that these fractures most often result from a. Automobile accidents b. Falls c. Physical abuse d. Sports injuries
B
Which Functional Test targets Instrumental Activities of Daily Living (IADLs) and Older Adults? A) GCS B) Functional Activities Questionnaire (FAQ) C) Now, Growth & Development, Activities of Daily Living, General Health, Environment, and Documentation (NGAGED) D) Mini-Mental Status Examination (MMSE)
B
Which factor should the nurse include when teaching a parent about the care of a newborn in a Pavlik harness for hip dysplasia? a. The harness may be removed with every diaper change. b. The harness is used to maintain the infants hips in flexion and abduction and external rotation. c. The harness is only the first step of treatment. d. The harness is worn for 2 weeks
B
Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery.
B
You're developing discharge instructions to the parents of a child who experiences atonic seizures. What information below is important to include in the teaching? A. "This type of seizure is hard to detect because the child may appear like he or she is daydreaming." B. "Be sure your child wears a helmet daily." C. "It is common for the child to feel extremely tired after experiencing this type of seizure." D. "Avoid high fat and low carbohydrate diets."
B
The nurse is caring for a Hispanic American client admitted with a diagnosis of diabetic ketoacidosis. Several family members are present. What examples of nonverbal communication would the nurse expect? Select all that apply. A) Maintaining eye contact B) Dramatic body language C) Smiling and shaking hands D) Avoiding any confrontations with staff E) Consistently expressing negative feelings F) Using gestures or facial expressions to express emotion or pain
B, C, D, F
The nurse assesses an older adult with a diagnosis of severe, late-stage AD. Which assessment findings would the nurse expect for this client? Select all that apply. A) Acute confusion B) Hallucinations C) Wandering D) Urinary Incontinence E) Difficulty eating
B, D, E
A 14-month-old child is admitted to the pediatric hospital with a fractured right femur. The child is placed in Bryant traction. When the parents see the child for the first time in traction, they are surprised to see both legs in traction and ask why. What information should the nurse share about Bryant traction? A) Putting both legs in traction keeps one leg from becoming longer than the other. B) Putting both legs in traction keeps the baby from turning over in bed and breaking his leg again. C) As a means of ensuring countertraction, both legs are placed in traction, and the buttocks are suspended off the bed. D) When the leg was x-rayed, the healthcare practitioner apparently discovered that the other leg was broken as well.
C
A 14-year-old girl in whom scoliosis has been diagnosed undergoes spinal fusion. On the first postoperative day her face is red, she is rigid, and she is crying because she is in pain. She has prescriptions for morphine sulfate for severe pain and an acetaminophen-codeine compound for moderate pain. What information should influence the nurse's choice of analgesic? A. One dose of morphine may be given, but the drug should be restricted thereafter because it is addictive. B. Adolescents tend to exaggerate their discomfort, particularly when they are immobilized by surgery or injury. C. Spinal fusion causes considerable pain during the early postoperative days, and morphine is the more effective analgesic. D. The acetaminophen-codeine compound is preferred because morphine can cause respiratory depression or respiratory arrest.
C
A 4-year-old child with a long leg cast complains of fire in his cast. The nurse should a. Notify the physician on his next rounds. b. Note the complaint in the nurses notes. c. Notify the physician immediately. d. Report the complaint to the next nurse on duty.
C
A patient who is bedridden, totally dependent in ADLs, has loss of mobility and verbal skills, and has agnosia is associated with what stage of Alzheimer's Disease? A) Early (Mild, Stage 1) B) Middle (Moderate, Stage 2) C) Late (Severe, Stage 3)
C
Apraxia in Alzheimer's is defined as: A) Loss of sensory comprehension, faces and sounds B) Impaired memory C) Inability to use words/objects correctly D) Inability to speak or understand
C
During a Glasgow Coma Scale assessment, you determine that the patient is experiencing an emergency according to the GCS calculated. What number would indicate an emergency? A) 9 B) 14 C) 5 D) 11
C
Meningitis is more common in: A) African American, Women B) Hispanic, Women C) African American, Men D) Caucasian, Men
C
The child with Down syndrome should be evaluated for which condition before participating in some sports? a. Hyperflexibility b. Cutis marmorata c. Atlantoaxial instability d. Speckling of iris (Brushfield spots)
C
The nurse is caring for a patient who has symptoms and risk factors for bacterial meningitis. For which symptoms must the nurse alert the health care provider? A) Capillary refill of 3 seconds B) Headache with nausea and vomiting C) Inability to move eyes laterally D) Oral temperature of 101.6
C
The nurse is caring for an 80-year-old patient who has Alzheimers disease who will begin taking rivastigmine (Exelon). What will the nurse include in the plan of care for this patient? a. Administer the drug once daily. b. Assist the patient to stand and walk. c. Give the drug with food to increase absorption. d. Use nonsteroidal anti-inflammatory drugs (NSAIDs) instead of acetaminophen for pain.
C
The nurse is helping to develop a plan of care for a patient who has advanced Alzheimers disease. The patient will be taking a new medication. Which is a realistic goal for this patient? a. Demonstrate improved cognitive function. b. Exhibit improved ability to provide self-care. c. Receive appropriate assistance for care needs. d. Show improved memory for recent events.
C
The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? A. Apple juice B. Grape juice C. Grapefruit juice D. Milk
C
The nursing instructor asks the student nurse caring for a client with Alzheimer's disease who has been prescribed donepezil (Aricept) how the drug works. Which response by the nursing student best explains the action of donepezil? A. "The reuptake of serotonin is blocked." B. "Donepezil prevents the increase in the protein beta amyloid." C. "It delays the destruction of acetylcholine by acetylcholinesterase." D. "Dopamine levels are increased."
C
This type of cerebral palsy is the MOST common, has sudden jerking movements, stiff muscles, and the patient "scissors" the legs & walks around on tiptoes: A) Ataxia B) Dyskinetic C) Spastic D) Rigid
C
What action is contraindicated when a child with Down syndrome is hospitalized? a. Determine the childs vocabulary for specific body functions. b. Assess the childs hearing and visual capabilities. c. Encourage parents to leave the child alone for extended periods of time. d. Have meals served at the childs usual meal times.
C
What is the priority need for a patient diagnosed with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Maintenance of nutrition and hydration d. Prevention of the patient from wandering
C
What should the nurse keep in mind when planning to communicate with a child who has autism? a. The child has normal verbal communication. b. Expect the child to use sign language. c. The child may exhibit monotone speech and echolalia. d. The child is not listening if she is not looking at the nurse
C
When infants are seen for fractures, which nursing intervention is a priority? a. No intervention is necessary. It is not uncommon for infants to fracture bones. b. Assess the familys safety practices. Fractures in infants usually result from falls. c. Assess for child abuse. Fractures in infants are often nonaccidental. d. Assess for genetic factors.
C
A child with hip dysplasia has undergone a closed reduction surgery. The nurse assesses the child 2 days after the surgery and feels that the treatment and care provided for the child were not effective. The nurse made this conclusion based on what findings? A) The child has a staggering gait. B) The child is unable to walk independently. C) The child has impaired muscle tone and flexibility. D) The child's femoral head did not return to the hip socket
D
A child with recently diagnosed idiopathic scoliosis has a mild structural curve. The child's mother asks whether the problem can be corrected with exercise. What should the nurse tell the mother concerning an exercise program? A) Exercise can be used if the child appears highly motivated B) Exercise might aggravate the curvature if the curve is severe C) Exercise is needed to correct the curvature without the need for a brace D) Exercise used in conjunction with a brace
D
A nurse assesses a 3-year-old diagnosed with autism spectrum disorder. Which finding is most associated with the child's disorder? The child: A.Has occasional toileting accidents B.Is unable to read children's books C.Cries when separated from a parent D.Continuously rocks in place for 30 minutes
D
A nurse is teaching a client and family about the characteristics of dementia of the Alzheimer type. What physiologic characteristic should the nurse include? A) Periodic exacerbations B) Aggressive acting-out behavior C) Hypoxia of selected areas of brain tissue D) Areas of brain destruction called senile plaques
D
After a pathogen compromises the blood-brain and blood-CSF barriers, infection will spread to the meninges for which reason? A) Spinal fluid has a rich erythrocyte content B) Glucose content of the spinal fluid is relatively high C) There's a build up of infectious exudate within the ventricular system D) CSF is devoid of the body's major defense system
D
Six weeks after birth an infant is found to have developmental dysplasia of the hip. The nurse explains to the parents the benefits of early treatment. What is the rationale for the immediate institution of corrective measures? A) Mobility will be delayed if correction is postponed. B) Traction is effective if it is used before toddlerhood. C) Infants are easier to manage in spica casts than are toddlers. D) Infants' cartilaginous hip joints promote molding of the acetabulum.
D
The nurse is monitoring a child with increased intracranial pressure who has been exhibiting decorticate posturing. On data collection, the nurse notes extension of the upper and lower extremities with internal rotation of the upper arms, wrists, knees, and feet. How should the nurse interpret the child's condition? A) Is unchanged B) Has improved C) Indicates decreased intracranial pressure D) Indicates a deterioration in neurological function
D
Which Functional Test targets Cognitive Function and Older Adults? A) GCS B) Functional Activities Questionnaire (FAQ) C) Now, Growth & Development, Activities of Daily Living, General Health, Environment, and Documentation (NGAGED) D) Mini-Mental Status Examination (MMSE)
D
Which child shows behaviors indicative of mental illness? a. 4-year-old who stuttered for 3 weeks after the birth of a sibling b. 9-month-old who does not eat vegetables and likes to be rocked c. 3-month-old who cries after feeding until burped and sucks a thumb d. 3-year-old who is mute, passive toward adults, and twirls while walking
D
Which nursing intervention is appropriate to assess for neurovascular competency in a child who fell off the monkey bars at school and hurt his arm? a. The degree of motion and ability to position the extremity b. The length, diameter, and shape of the extremity c. The amount of swelling noted in the extremity and pain intensity d. The skin color, temperature, movement, sensation, and capillary refill of the extremity
D
Which statement by the mother of an adolescent being discharged after spinal fusion for severe scoliosis indicates the need for further teaching? A) "Those exercises the physical therapist showed us were not too hard." B) "I'll see you in a month; we'll be back fairly regularly." C) "I have to pick up some more T-shirts on the way home." D) "I am glad we chose surgery. Now it is all over and done."
D
A mother has recently been informed that her child has Down's syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down's syndrome? A) Simian crease B) Brachycephaly C) Oily skin D) Hypotonicity
C
A neonate has been brought to the ER by his mother. The nurse assess the child and suspects that they child may have hydrocephalus. Which observations by the nurse would indicate this condition? A) Bulging fontanel, low-pitched cry B) Depressed fontanel, low-pitched cry C) Bulging fontanel, eyes rotated downward D) Depressed fontanel, eyes rotated downward
C
A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take? a. Start fluids via a large-bore catheter. b. Turn the clients head to the side. c. Administer IV push diazepam. d. Prepare to intubate the client.
B
A nurse assesses a client with Alzheimers disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete? a. Assess religious and spiritual needs while in the hospital. b. Identify the clients ability to perform self-care activities. c. Evaluate the clients reaction to a change of environment. d. Ask the client about relationships with family members.
C
A parent asks the nurse why a developmental assessment is being conducted for a child during a routine well-child visit. The nurse answers based on the knowledge that routine developmental assessments during well-child visits are a. Not necessary unless the parents request them b. The best method for early detection of cognitive disorders c. Frightening to parents and children and should be avoided d. Valuable in measuring intelligence in children
B
A 2 year old child is admitted to the pediatric unit with a diagnosis of bacterial meningitis. Which intervention would be appropriate for the nurse to perform FIRST? A) Obtain a urine specimen B) Draw ordered laboratory tests C) Place the toddler in respiratory isolation D) Explain the treatment plan to the parents
C
A patient diagnosed with Alzheimer disease has a dressing and grooming self-care deficit. Designate the appropriate interventions to include in the patients plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patients name and name of the item. c. Administer antianxiety medication before bathing and dressing. d. Provide necessary items, and direct the patient to proceed independently. e. If the patient resists, use distraction and then try again after a short interval.
A, B, E
A 4-year-old child is admitted to the pediatric neurologic service with a seizure disorder. Shortly after admission, while in bed, the child has a generalized seizure. What nursing actions are most appropriate? Select all that apply. A) Assessing the seizure B) Taking the child's vital signs C) Turning the child on the side D) Pulling the padded side rails up E) Initiating oxygen administration
A, C, D
A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells
A, C, D
A nurse should expect which cerebral spinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis? Select all that apply. a. Elevated white blood count (WBC) b. Decreased protein c. Decreased glucose d. Cloudy in color e. Increase in red blood cells (RBC)
A, C, D
A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.
A, D, F
A neonate is admitted to the unit with a diagnosis of bacterial meningitis. The nurse is aware that the priority assessment will include which of the following? A) Hypothermia, irritability, and poor feeding B) Positive Babinski's reflex, mottling, and pallor C) Headache, nuchal rigidity, and developmental delays D) Positive Moro's embrace reflex, hyperthermia, and sunken fontanel
A
An intubated child is brought to the emergency department while having a seizure that has been progressing for 20 minutes. Which drug will the nurse anticipate administering to this patient? a. Diazepam (Valium) b. Phenobarbital (Luminal) c. Phenytoin (Dilantin) d. Valproic acid (Depakote)
A
An older adult diagnosed with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patients family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult diapers. d. Make sure the older adult does not eat nonfood items.
A
The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be A) change in level of consciousness. B) inability to focus visually. C) loss of primitive reflexes. D) unequal pupil size.
A
The nurse is caring for a patient who has a seizure disorder. The nurse notes that the patient has reddened gums that bleed when oral care is given. The nurse recognizes this finding as a. an adverse effect of the phenytoin. b. a drug interaction with aspirin. c. a symptom of hepatotoxicity. d. a sign of poor self-care.
A
The nurse is preparing to administer phenytoin (Dilantin) to a patient who has a seizure disorder. The patient appears drowsy, and the nurse notes that the last random serum drug level was 18 mcg/mL. What action will the nurse take? a. Administer the dose since the patient is not toxic. b. Contact the provider to discuss decreasing the phenytoin dose. c. Give the drug and monitor closely for adverse effects. d. Report drug toxicity to the providers.
A
A parent expresses concern that a 5-year-old child may develop epilepsy because the child experienced a febrile seizure at age 18 months. What will the nurse tell this parent? a. A child who has had a febrile seizure is considered to have epilepsy. b. A small percentage of children who have febrile seizures develop epilepsy. c. I recommend discussing prophylactic anticonvulsant drugs with the provider. d. Treat fevers aggressively with aspirin and NSAIDs to prevent seizures.
B
A parent whose child has been diagnosed with a cognitive deficit should be counseled that intellectual impairment a. Is usually due to a genetic defect b. May be caused by a variety of factors c. Is rarely due to first trimester events d. Is usually caused by parental intellectual impairment
B
A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety? a. Place throw rugs on tile or wooden floors. b. Place locks at the tops of doors. c. Encourage daytime napping. d. Obtain a bed with side rails.
B
A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Strategically place large clocks and calendars.
B
A patient diagnosed with stage 1 Alzheimer disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Risk for injury b. Impaired memory c. Self-care deficit d. Caregiver role strain
B
A patient has recently begun taking phenytoin (Dilantin) for a seizure disorder. The nurse notes a reddish-brown color to the patients urine. Which action will the nurse take? a. Ask the provider to order a serum drug level. b. Reassure the patient that this is a harmless side effect. c. Report possible thrombocytopenia to the provider. d. Request an order for a urinalysis and creatinine clearance.
B
A patient is diagnosed with epilepsy and asks the nurse what may have caused this condition. The nurse explains that epilepsy is most often a. caused by head trauma. b. idiopathic in origin. c. linked to a stroke. d. related to brain anoxia.
B
After shunt procedure, the nurse would monitor the patient's neurologic status by using the A) electroencephalogram. B) GCS. C) National Institutes of Health Stroke Scale. D) Monro-Kellie doctrine.
B
An infant is found to have hydrocephalus. Which assessment finding alerts the nurse to suspect increasing intracranial pressure? A) Sunken eyes B) Projectile vomiting C) Depressed fontanels D) Narrowing pulse pressure
B
An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors homes. Alzheimer disease was subsequently diagnosed. Which stage of Alzheimer disease is evident? a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late)
B
In caring for a 9 year old child immediately after a head injury, a nurse notes a BP of 110/60, HR of 78, dilated and nonreactive pupils, minimal response to pain, and slow response to name. Which symptom should cause the nurse the most concern? A) Vital signs B) Nonreactive pupils C) Slow response to name D) Minimal response to pain
B
The Glasgow Coma Scale consists of an assessment of: a. Pupil reactivity and motor response b. Eye opening and verbal and motor responses c. Level of consciousness and verbal response d. ICP and level of consciousness
B
The nurse is caring for a child following a shunt insertion on the right side of the head to relieve hydrocephalus. What is the priority intervention for the nurse to include in the plan of care? A) Place the child flat in the bed on the right side B) Place the child flat in the bed on the left side C) Place the child in a semi-Fowler's position D) Place the child in an upright position
B
The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? A) Aligning the neck with the body B) Clustering many nursing activities C) Elevating the head of the bed 30 degrees D) Providing stool softeners or laxatives as ordered
B
The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. Which statement should the nurse include when preparing the child? a. Pain medication will be given. b. The scan will not hurt. c. You will be able to move once the equipment is in place. d. Unfortunately no one can remain in the room with you during the test.
B
What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure? a. Guide the child to the floor if standing and go for help. b. Turn the childs body on the side. c. Place a padded tongue blade between the teeth. d. Quickly slip soft restraints on the childs wrists.
B
What should be the nurses first action when a child with a head injury complains of double vision and a headache, and then vomits? a. Immobilize the childs neck. b. Report this information to the physician. c. Darken the room and put a cool cloth on the childs forehead. d. Restrict the childs oral fluid intake.
B
What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by the intravenous route to control seizures? Select all that apply. a. It must be given with D5 1/2NS. b. The child will require monitoring of therapeutic serum levels while taking this medication. c. Dilantin should be given with food because it causes gastrointestinal distress. d. It must be given in normal saline. e. It must be filtered.
B, D, E
A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, Will the medication my mother is taking improve her dementia? How should the nurse respond? a. It will allow your mother to live independently for several more years. b. It is used to halt the advancement of Alzheimers disease but will not cure it. c. It will not improve her dementia but can help control emotional responses. d. It is used to improve short-term memory but will not improve problem solving.
C
A nurse prepares to discharge a client with Alzheimers disease. Which statement should the nurse include in the discharge teaching for this clients caregiver? a. Allow the client to rest most of the day. b. Place a padded throw rug at the bedside. c. Install deadbolt locks on all outside doors. d. Provide a high-calorie and high-protein diet.
C
An older adult was stopped by police for driving through a red light. When asked for a drivers license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Memory impairment
C
Nursing care of the infant who has had a myelomeningocele repair should include a. Securely fastening the diaper b. Measurement of pupil size c. Measurement of head circumference d. Administration of seizure medications
C
What is the best response to a father who tells the nurse that his son daydreams at home and his teacher has observed this behavior at school? a. Your son must have an active imagination. b. Can you tell me exactly how many times this occurs in one day? c. Tell me about your sons activity when you notice the daydreams. d. He is probably overtired and needs more rest.
C
When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. donepezil (Aricept) b. rivastigmine (Exelon) c. memantine (Namenda) d. galantamine (Razadyne)
C
Which intervention is appropriate to use for patients diagnosed with either delirium or dementia? a. Speak in a loud, firm voice. b. Touch the patient before speaking. c. Reintroduce the health care worker at each contact. d. When the patient becomes aggressive, use physical restraint instead of medication.
C
Which type of seizures involves both hemispheres of the brain? a. Focal b. Partial c. Generalized d. Acquired
C
After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I will wear my medical alert bracelet at all times. b. While taking my epilepsy medications, I will not drink any alcoholic beverages. c. I will tell my doctor about my prescription and over-the-counter medications. d. If I am nauseated, I will not take my epilepsy medication.
D
After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. To prevent complications, I will drink at least 2 liters of water daily. b. This medication will stop me from getting an aura before a seizure. c. I will not drive a motor vehicle while taking this medication. d. Even when my seizures stop, I will continue to take this drug.
D
The father of a child recently diagnosed with developmental delay is very rude and hostile toward the nurses. This father was cooperative during the childs evaluation a month ago. What is the best explanation for this change in parental behavior? a. The father is exhibiting symptoms of a psychiatric illness. b. The father may be abusing the child. c. The father is resentful of the time he is missing from work for this appointment. d. The father is experiencing a symptom of grief.
D
The genetic testing of a child with Down syndrome showed that the disorder was caused by chromosomal translocation. The parents ask about further genetic testing. Based on the nurse's knowledge of genetics, the most appropriate recommendation is: a. no further genetic testing of the family is indicated. b. the child should be retested to confirm the diagnosis of Down syndrome. c. the mother should be tested if she is over age 35. d. the parents can be tested, since it might be hereditary.
D
The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of nursing assessment to detect early signs of a worsening condition is a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness
D
The nurse provides teaching for a patient who will begin taking phenytoin. Which statement by the patient indicates understanding of the teaching? a. If I develop a rash, I should take diphenhydramine to control the itching. b. If I experience bleeding gums, I should stop taking the medication immediately. c. I may develop diabetes while I am taking this medication. d. I should not be alarmed if my urine turns reddish-brown.
D
The nurse reads in the chart that the patient has AD and is displaying agnosia. What does the nurse expect to observe? A) Wanders around and is at a risk for elopement B) Is unable to remember the purpose of a fork C) Is telling everyone she is Queen Elizabeth D) Does not recognize herself or members of her family
D
Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury? a. Rapid, shallow breathing b. Irregular, rapid heart rate c. Increased diastolic pressure with narrowing pulse pressure d. Confusion and altered mental status
D
