Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
New Updated Nursing Latest Test Bank Ignatavicius Chapter 21 TEST BANK, Chapter 34 : Critical Care of Patients With Shock Ignatavicius : Medical-Surgical Nursing, 10th Edition, Iggy Ch 40, chapter 41 : critical care of patients with neuro emergencies QUESTIONS AND ANSWERS GUARANTEED SUCCESS GRADED A+
Typology: Exams
1 / 29
The nurse learning about infection discovers that which factor is the best and MOST important barrier to infection? A. Colonization by host bacteria B. Gastrointestinal secretions C. Inflammatory process D. Skin and mucous membranes - <<< ANSWER D. The skin and mucous membranes are two of the most important barriers against infection. A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections? a. Auditing staff members' hand hygiene practices b. Ensuring clients are placed in appropriate isolation c. Establishing a policy to remove urinary catheters quickly d. Teaching staff members about infection control methods - <<< ANSWER A. All methods will help prevent infection; however, health care workers' lack of hand hygiene is the biggest source of health care-associated infections. The manager can start with a hand hygiene audit to see if this is a contributing factor. An assistive personnel asks why brushing a clients' teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is BEST? A. "It mechanically removes biofilm on teeth." B. "It's easier to clean all surfaces with a brush." C. "Oral care is important to all our clients." D. "Toothbrushes last longer than oral swabs." - <<< ANSWER A. Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them. A client is admitted with possible sepsis. Which action will the nurse perform FIRST? A. Administer antibiotics B. Give an antipyretic C. Place the client in isolation D. Obtain specified cultures - <<< ANSWER D. Prior to administering antibiotics, the nurse obtains the prescribed cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known. A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is MOST important? A. Consult with the primary health care provider about obtaining stool cultures. B. Delegate frequent perineal care to assistive personnel C. Place the client on NPO status until the diarrhea resolves. D. Request a prescription for an antidiarrheal medication - <<< ANSWER A. Hospitalized patients who have three or more stools a day for 2 or more days are suspected of having an infection with CLOSTRIDIUM DIFFICILE. The nurse will inform the primary health care provider and request stool cultures.
A nurse is observing as an assistant personnel (AP) performs hygiene and provides comfort measures to a client with an infection. What action by the AP requires intervention by the nurse? A. Not using gloves while combing the client's hair. B. Rinsing the client's commode pan after use. C. Ordering an oscillating fan for the client. D. Wearing gloves when providing perianal care. - <<< ANSWER C. Fans in client care areas are discouraged because they can disperse airbourne or droplet-bourne pathogens. A client is to receive a fecal microbiota transplantation tomorrow (FMT). What action by the nurse is BEST? A. Administer bowel cleansing as prescribed B. Educate the client on immunosuppressive drugs. C. Inform the client they will drink a thick liquid. D. Place a nasogastric tube to intermittent suction. - <<< ANSWER A. The usual route of delivering an FMT is via a colonoscopy, so the client would have a bowel cleansing as prescribed for that procedure. A nurse manager is preparing an educational session for floor nurses on drug-resistant organisms. Which statement below indicates the need to review this information? A. "MRSA can be hospital- or community-acquired" B. "Vancomycin-resistant Enterococcus can live on surfaces and be infectious for weeks." C. "Carbapenem-resistant Enterobacteriaceae is hard to treat due to enzymes that break down antibiotics." D. "If you leave work wearing your scrubs, go directly home and wash them right away."
B. Show the family how to avoid spreading the disease. C. Reassure the family that they will not get the infection. D. Tell the family it is important that they visit the client. - <<< ANSWER B. Visitors may be apprehensive about visiting a client in Transmission-Based Precautions. The nurse would reassure the visitors that taking appropriate precautions will minimize their risks. A nurse is caring for a client who has MRSA infection cultured from the urine. What action by the nurse is MOST appropriate? A. Prepare to administer vancomycin. B. Strictly limit visitors to immediate family only. C. Wash hands only after taking off gloves after care. D. Wear a respirator when handling urine output. - <<< ANSWER A. Vancomycin is one of the few drugs approved to treat MRSA. The others include linezolid and ceftroline fosamil. Delafloxacin is a new antibiotic approved to treat MRSA. A hospitalized client is placed on Contact Precautions. The client needs to have a CT scan. What action by the nurse is MOST appropriate? A. Ensure the radiology department is aware of the Isolation Precautions. B. Plan to travel with the client to ensure appropriate precautions are used. C. No special precautions are needed when this client leaves the unit. D. Notify the primary health care provider that the client cannot leave the room. - <<< ANSWER A. Clients in isolation will leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse will ensure that the receiving department is aware of the Isolation Precautions needed to care for the client. A nurse receives report from the lab on a client who was admitted with a fever. The lab tech states that the client has "a shift to the left" on the WBC count. What action by the nurse is MOST important? A. Document findings and continue monitoring. B. Notify the provider and request antibiotics. C. Place the client in protective isolation. D. Tell the client this signifies inflammation. - <<< ANSWER B. A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse is caring for clients understands that which factors must be present to transmit infection? (SATA) A. Colonization B. Host C. Mode of transmission D. Portal of entry E. Reservoir F. Poor hygiene - <<< ANSWER B, C, D, E. Factors must be present in order to transmit infection include a host with a portal of entry, a mode of transmission, and a reservoir.
Which statements are true regarding Standard Precautions? (SATA) A. Always wear a gown when performing hygiene on a client. B. Sneeze into your sleeve or into a tissue that you throw away. C. Remain 3 feet away from any client who has an infection. D. Use personal protective equipment as needed for client care. E. Wear gloves when touching clients' excretions or secretions. F. Cohorting clients who have infections caused by the same organism. - <<< ANSWER D, E. Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other personal protective equipment is used based on the care being given. The nurse learns that effective antimicrobial therapy requires which factors to be present? (SATA) A. Appropriate drug B. Proper route of administration C. Standardized peak levels D. Sufficient dose E. Sufficient length of treatment F. Appropriate trough levels - <<< ANSWER A, B, D, E. In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient dose, for a sufficient length of time, and given via the appropriate route. A client is being admitted with suspected TB. What actions by the nurse are BEST? (SATA) A. Admit the client to a negative-air-flow room. B. Maintain a distance of 3 feet from the client at all times. C. Obtain specialized respirations for caregiving D. Other than wearing gloves, no special actions are needed. E. Wash hands with chlorhexidine after providing care. F. Assure client has a respirator for moving between departments. - <<< ANSWER A, C. A client with suspected TB is admitted with AIRBOURNE Precautions, which includes a negative air-flow room and a special N95 or PAPR masks to be worn when providing care. A nurse asks the supervisor why older adults are more prone to infection than other adults. What reasons does the supervisor give? (SATA) a. Age-related decrease in immune function b. Decreased cough and gag reflexes c. Diminished acidity of gastric secretions d. Increased lymphocytes and antibodies e. Thinning skin that is less protective f. Higher rates of chronic illness - <<< ANSWER A, B, C, E, F. Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflexes, decreased acidity of
gastric contents, thinning skin, fewer lymphocytes and antibodies, and higher rates of chronic illness. A client with an infection has a fever. What actions by the nurse help increase the client's comfort? (SATA) A. Administer antipyretics around the clock. B. Change the client's gown and linens when damp. C. Offer cool fluids to the client frequently D. Place ice bags in the armpits and groin. E. Provide a fan to help cool the client. F. Sponging the client with tepid water. - <<< ANSWER B, C, F. Comfort measures appropriate for this client include offering frequent cool drinks, and changing linens or the gown when damp. A nurse plans care for a client who is at risk for infection. Which interventions will the nurse implement to prevent infection? (SATA) A. Administer prophylactic antibiotics. B. monitor WBC count and differential C. Screen all visitors for infections D. Implement Transmission-Based Precautions E. Promote sufficient nutritional intake. - <<< ANSWER B, C, E. Nursing interventions for clients at risk for infection include monitoring WBC count and differential, screening visitors for infections and infectious disease, and promoting sufficient nutritional intake. A nurse cares for several clients on an inpatient unit. Which infection control measures will the nurse implement? (SATA) A. Wear a gown when contact of clothing with body fluids is anticipated. B. Teach clients and visitors respiratory hygiene techniques. C. Obtain powered air purifying respirators for all staff members. D. Do not use alcohol-based hand rub between client contacts. E. Disinfect frequently touched surfaces in client-care areas. - <<< ANSWER A, B, E. Infection control measures appropriate to all clients include hand hygiene with alcohol based rub or soap between client contact, procedures for routine care, cleaning and disinfection of frequently contaminated surfaces, and wearing PPE when contamination is anticipated. A nurse is caring for a client who suffered massive blood loss after trauma. How does the nurse correlate the blood loss with the client's mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP. - <<< ANSWER b. Lower blood volume lowers MAP. ANS: B Lower blood volume will decrease MAP. The other answers are not accurate
A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the client was last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess using the MEWS score. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion. - <<< ANSWER b. Assess using the MEWS score. ANS: B Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse would conduct a thorough assessment of the patient, focusing on indicators of perfusion. The MEWS score (Modified Early Warning Score) was developed to identify clients at risk for deterioration. The client may need pain medication, but this is not the priority at this time. Documentation would be done thoroughly but would be done after the assessment. The nurse would not increase the rate of the IV infusion without an order The nurse gets the hand-off report on four clients. Which client would the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours - <<< ANSWER a. Client with a blood pressure change of 128/74 to 110/88 mm Hg This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowingpulse pressure, all of which may be indications of worsening perfusion status and possibleshock. The nurse would assess this client first. The client with the unchanged oxygensaturation is stable at this point. Although the client with a change in pulse has a slower rate, itis not an indicator of shock since the pulse is still within the normal range; it may indicate thatthe client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urineoutput of 40 mL/hr is above the normal range, which is 30 mL/hr. A nurse is caring for a client after surgery who is restless and apprehensive. The assistive personnel (AP) reports the vital signs and the nurse sees that they are only slightly different from previous readings. What action does the nurse delegate next to the AP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the side. d. Stay with the client and reassure him or her - <<< ANSWER b. Measure urine output from the catheter..
ANS: B Urine output changes are a sensitive early indicator of shock. The nurse would delegate emptying the urinary catheter and measuring output to the AP as a baseline for hourly urine output measurements. The AP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments.Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic. - <<< ANSWER a. "High glucose is common in shock and needs to be treated." High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the range of 140 to 180 mg/dL (7.7 to 10 mmol/L.Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not "made" the client diabetic. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3(3.8 109/L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6°C). What action by the nurse takes priority? a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the primary health care provider immediately. d. Prepare to administer insulin per sliding scale. - <<< ANSWER c. Notify the primary health care provider immediately. This client has several indicators of sepsis with systemic inflammatory response. The nurse would notify the primary health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may need insulin if blood glucose is being regulated tightly. A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations d. Take medications as prescribed. - <<< ANSWER b. Drink fluids on a regular schedule. Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids
on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn't give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration. A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse take priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain a pulse oximetry reading d. Start two large-bore IV catheters. - <<< ANSWER b. Ensure the client has a patent airway. ANS: B Airway is the priority, followed by breathing (pulse oximetry) and circulation (IVs and direct pressure) A client is receiving nor-epinephrine for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denies chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours - <<< ANSWER a. Alert and oriented, answering questions Normal cognitive function is a good indicator that the client is receiving the benefits of nor-epinephrine. The brain is very sensitive to changes in oxygenation and perfusion.Nor-epinephrine can cause chest pain as an adverse reaction, so the absence of chest pain is good but does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so. A nurse is caring for a client who has a diagnosis of multiple organ dysfunction syndrome(MODS) who will be receiving sodium nitroprusside via IV infusion. What action by the nurse causes the charge nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable ("smart") IV pump. c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vitals. - <<< ANSWER c. Removing the IV bag from the brown plastic cover Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct
A nurse on the medical-surgical unit is caring for a client in shock and assesses the following:Respiratory rate: 10 breaths/min Pulse: 136 beats/min Blood pressure: 92/ mm Hg Level of consciousness: responds to voice Temperature: 101.5° F (38.5° C)Urine output for the last 2 hours: 40 mL/hr. What action by the nurse is best? a. Transfer the client to the Intensive Care Unit. b. Continue monitoring every 30 minutes. c. Notify the unit charge nurse immediately. d. Call the Rapid Response Team - <<< ANSWER d. Call the Rapid Response Team This client has a MEWS score of 7 (RR: 0, P: 3, SBP: 1, LOC: 1, Temperature: 1, UO: 1). Scores above 5 are associated with a high risk of death and ICU admission. The most important action for the nurse is to notify the Rapid Response Team so that timely interventions can be initiated. The client most likely will be transferred to the ICU, but an order is required. Monitoring the client every 30 minutes is appropriate, but the nurse needs to obtain care for the client. The charge nurse is a valuable resource, but the best action is to notify the Rapid Response Team. A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the primary health care provider? a. Creatinine: 0.9 mg/dL (68.6 mcmol/L) b. Lactate: 5.4 mg/dL (6 mmol/L) c. Sodium: 150 mEq/L (150 mmol/L) d. White blood cell count: 11,000/mm3 (11 109/L) - <<< ANSWER b. Lactate: 5. mg/dL (6 mmol/L) A lactate level of 5.4 mg/dL (6 mmol/L) is high and is indicative of possible shock. Acreatinine level of 0.9 mg/dL (68.6 mcmol/L) is normal. A sodium level of 150 mEq/L (150mmol/L) is slightly high but does not need to be communicated. A white blood cell count of11,000/mm3 (11 109/L) is slightly high but is not as critical as the lactate level. A nurse receives hand-off report from the emergency department on a new admission suspected of having septic shock. The client's qSOFA score is 3. What action by the nurse is best? a. Plan to calculate a full SOFA score on arrival. b. Contact respiratory therapy about ventilator setup. c. Arrange protective precautions to be implemented. d. Call the hospital chaplain to support the family - <<< ANSWER a. Plan to calculate a full SOFA score on arrival. The qSOFA score is an abbreviated Sequential Organ Failure Assessment (or "quick"). A score of 3 is high and requires the nurse to assess the client further for organ impairment. The client may or may not need a ventilator, but that in not specified in the score. The client does not need protective precautions. The client's family may well need support, but the nurse would assess their needs and wishes prior to calling the chaplain.
A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's stern-al wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. "All my friends and neighbors are planning a party for me." b. "I hope I can get my water turned back on when I get home." c. "I am going to have my daughter scoop the cat litter box." d. "My grand-kids are so excited to have me coming home!" - <<< ANSWER b. "I hope I can get my water turned back on when I get home." ANS: B All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs.However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes. A client with MODS has been started on dobutamine. What assessment finding requires the nurse to communicate with the primary health care provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr - <<< ANSWER c. Report of chest heaviness Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect ofdobutamine. While taking dobutamine, the oxygen requirements of the heart are increased dueto increased myocardial workload, and may cause ischemia. Without knowing the client'sprevious blood pressure or pedal pulses, there is not enough information to determine if theseare an improvement or not. A urine output of 32 mL/hr is acceptable. The nurse studying shock understands that the common signs and symptoms of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased systemic perfusion - <<< ANSWER a. Anaerobic metabolism c. Hypotension The common signs and symptoms of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function,and increased perfusion are not the cause of common signs and symptoms of shock.
The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures f. Limiting the client's visitors until more stable - <<< ANSWER a. Assessing and identifying clients at risk c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures, Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique,and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change. Limiting the client's visitors is not a caring action. The nurse would ensure they perform proper hand hygiene on entering and leaving the room and that visitors are not ill themselves The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.), a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Over hydration f. Use of diuretics - <<< ANSWER a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition f. Use of diuretics ANS: A, B, C, D, F Immobility, decreased thirst response, diminished immune response, malnutrition, and use of diuretics can place the older adult at higher risk of developing shock. Over hydration is not a common risk factor for shock.DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink
c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance - <<< ANSWER a. Bringing the client warm blankets b. Giving the client hot tea to drink d. Reorienting the client as needed e. Sitting with the client for reassurance The AP can bring the client warm blankets, reorient the client as needed to decrease anxiety,and sit with the client for reassurance. If the nurse assesses the client is safely able to swallow,small amounts of fluids would be allowed. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism. The nurse is caring for a client with suspected septic shock. What does the nurse prepare to do within 1 hour of the client being identified as possibly having sepsis? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures. f. Administer rapid bolus of IV crystalloids. - <<< ANSWER a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. e. Obtain blood cultures. f. Administer rapid bolus of IV crystalloids. Within the first hour of suspecting severe sepsis, the nurse would draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), administer antibiotics (after the cultures have been obtained), begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L. and administer vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure equal to or > 65 mm Hg. Initiating hemodynamic monitoring would be done after these "bundle" measures have been accomplished. The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate. Which statement by the client indicates a need for further teaching? a. "I will rotate injection sites to prevent skin irritation." b. "I need to avoid large crowds and people with infection." c. "I should report any flulike symptoms to my primary health care provider." d. "I will report any signs of infection to my primary health care provider." - <<< ANSWER "I should report any flulike symptoms to my primary health care provider."
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor? a. Peripheral edema b. Facial flushing c. Tachycardia d. Fever - <<< ANSWER Facial flushing A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern? a. Request a prescription for an antispasmodic drug such as baclofen. b. Prepare the client for deep brain stimulation surgery. c. Refer the client to a massage therapist to relax the muscles. d. Consult with the occupational therapist for self-care assistance. - <<< ANSWER Request a prescription for an antispasmodic drug such as baclofen. A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching? a. "Be sure that you use a wheelchair when you go out in public." b. "Wear an undergarment brief at all times in case of incontinence." c. "Avoid overexertion, stress, and extreme temperature if possible." d. "Avoid having sexual intercourse to conserve energy." - <<< ANSWER "Avoid overexertion, stress, and extreme temperature if possible." A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? a. Initiate oxygen via a nasal cannula. b. Recheck the client's blood pressure. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker. - <<< ANSWER Palpate the bladder for distention. The nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status. - <<< ANSWER Evaluate respiratory status. A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury. What other assessment finding will the nurse anticipate for this client?
a. Quadriplegia b. Flaccid bowel c. Spastic bladder d. Tetraparesis - <<< ANSWER Flaccid bowel The nurse is collaborating with the occupational therapist to assist a client with a complete cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid would be most appropriate for the client to meet this outcome? a. Rolling walker b. Quad cane c. Adjustable crutches d. Sliding board - <<< ANSWER Sliding board The nurse is caring for a 60-year-old female client who sustained a thoracic spinal cord injury 10 years ago. For which potential complication will the nurse assess during this client's care? a. Fracture b. Malabsorption c. Delirium d. Anemia - <<< ANSWER Fracture A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I don't understand the need for rehabilitation; the paralysis will not go away and it will not get better." How would the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let your primary health care provider know." b. "Rehabilitation programs have helped many patients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first." - <<< ANSWER "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." A nurse cares for a client with a spinal cord injury. With which interprofessional health team member would the nurse collaborate to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager - <<< ANSWER Occupational therapist
After teaching a client with a high thoracic spinal cord injury, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate." - <<< ANSWER "I'll use my incentive spirometer every 2 hours while I'm awake." A client is scheduled for a percutaneous endoscopic lumbar discectomy. Which statement by the client indicates a need for further teaching? a. "I should have a lot less pain after surgery." b. "I'll be in the hospital for 2 to 3 days." c. "I should not have any major surgical complications." d. "I could possibly get an infection after surgery." - <<< ANSWER "I'll be in the hospital for 2 to 3 days." A nurse assesses clients at a community center. Which client is at greatest risk for low back pain? a. A 24-year-old female who is 25 weeks pregnant. b. A 36-year-old male who uses ergonomic techniques. c. A 53-year-old female who uses a walker. d. A 65-year-old female with osteoarthritis. - <<< ANSWER A 65-year-old female with osteoarthritis. A nurse teaches a client who is recovering from an open traditional cervical spinal fusion. Which statement would the nurse include in this client's postoperative instructions? a. "Only lift items that are 10 lb (4.5 kg) or less." b. "Wear your neck brace whenever you are out of bed." c. "You must remain in bed for 3 weeks after surgery." d. "You will be prescribed medications to prevent graft rejection." - <<< ANSWER "Wear your neck brace whenever you are out of bed." A nurse assesses a client who is recovering from an open anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the primary health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing
d. Inability to shrug shoulders - <<< ANSWER Auscultated stridor A nurse assesses the health history of a client who is prescribed ziconotide for chronic low back pain. Which assessment question would the nurse ask? a. "Are you taking a nonsteroidal anti-inflammatory drug?" b. "Have you been diagnosed with a mental health problem?" c. "Are you able to swallow oral medications?" d. "Do you smoke cigarettes or any illegal drugs?" - <<< ANSWER "Have you been diagnosed with a mental health problem?" A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which statement(s) would the nurse include in this education? (Select all that apply.) a. "Participate in an exercise program to strengthen back muscles." b. "Purchase a mattress that allows you to adjust the firmness." c. "Wear flat instead of high-heeled shoes to work each day." d. "Keep your weight within 20% of your ideal body weight." e. "Avoid prolonged standing or sitting, including driving." - <<< ANSWER "Participate in an exercise program to strengthen back muscles." "Wear flat instead of high-heeled shoes to work each day." "Avoid prolonged standing or sitting, including driving." A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data would the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies - <<< ANSWER Spiritual beliefs Family support Level of independence Previous coping strategies After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the his understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of his injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection."
e. "I should be able to have an erection with stimulation." - <<< ANSWER "Ejaculation may not be as predictable as before." "I may urinate with ejaculation but this will not cause infection." "I should be able to have an erection with stimulation." A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion. Which complications would the nurse report to the primary health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache - <<< ANSWER Incisional bulging Clear drainage on the dressing Sudden and severe headache A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. What actions would the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Reposition the client off of the reddened areas. d. Get the client out of bed and into a chair several times a day. e. Apply a pressure-reducing mattress. - <<< ANSWER Reposition the client off of the reddened areas. Apply a pressure-reducing mattress. A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation - <<< ANSWER Heart rate of 34 beats/min Urine output less than 30 mL/hr Decreased level of consciousness A nurse plans care for a client with a halo fixator. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Remove the vest for client bathing. b. Assess the pin sites for signs of infection.
c. Loosen the pins when sleeping. d. Decrease the patient's oral fluid intake. e. Assess the chest and back for skin breakdown. - <<< ANSWER Assess the pin sites for signs of infection. Assess the chest and back for skin breakdown. The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke? a. Age greater than or equal to 75 b. Blood pressure greater than or equal to 160/ c. Unilateral weakness during a TIA d. TIA symptoms lasting less than a minute - <<< ANSWER c The client who has a TIA is at risk for a stroke is he or she has one-sided (unilateral) weakness during a TIA. Risk factors also include an age greater than or equal to 60, blood pressure greater than or equal to 140/90 (either or both systolic and diastolic), and/or a long duration of TIA symptoms. One minute is not a very long time for symptoms to occur. The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? a. Client's symptoms occurred slowly over several hours. b. Client because increasingly lethargic and drowsy. c. Client reported severe headache before other symptoms. d. Client has a long history of atrial fibrillation. - <<< ANSWER d The major cause of embolic strokes is a history of heart disease, especially atrial fibrillation. Most clients who have an embolic stroke have acute sudden neurologic symptoms but stay alert rather than lethargic. Decreasing level of consciousness and severe headache are more common in clients who have hemorrhagic strokes. A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time? a. Assess the client for hypoglycemia and hypoxia. b. Place the client on his or her side. c. Prepare for administration of a fibrinolytic agent. d. Start a continuous IV heparin sodium infusion. - <<< ANSWER a The cause of a sudden decline in level of consciousness may or may not be related to a neurologic health problem. Therefore, the client must be evaluated for other common causes,
especially hypoglycemia and hypoxia. Placing the client on his or her side may be helpful to prevent aspiration in case the client experiences vomiting, but the clinical situation does not indicate that the client has nausea or vomiting. Administering either an anticoagulant like heparin or a fibrinolytic agent assumes that the client has an acute ischemic stroke, which has not been confirmed through imaging tests. The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse's teaching? a. "I will use "yes" and "no" questions when communicating with the client." b. "I will remind the client frequently to not get out of bed without help." c. "I will offer a urinal every hour to the client due to incontinence." d. "I will feed the client slowly using soft or pureed foods." - <<< ANSWER b The client who has left-sided weakness has likely had a right-sided stroke in the brain. Clients who have strokes on the right side of the brain tend to be very impulsive and exhibit poor judgment. Therefore, to keep the client safe, the staff will need to remind the client to stay in bed unless he has assistance to prevent falling. There is no evidence in the clinical situation that the client has aphasia (which is less common in those with right-sided strokes), difficulty swallowing, or urinary incontinence. A nurse receives a hand-off report on a female client who had a left-sided stroke with homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder and bowel retention and/or incontinence. b. Listen to the client's lungs after eating or drinking for diminished breath sounds. c. Support the client's left side when sitting in a chair or in bed. d. Remind the client to move her head from side to side to increase her visual field. - <<< ANSWER d Homonymous hemianopsia is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. This condition is not related to bladder function, difficulty swallowing, or lack A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain?
a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset - <<< ANSWER d The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical. The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct about the administration of this drug? a. The recommended time for drug administration is within 90 minutes after admission to the emergency department. b. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. c. The maximum dosage of the drug, including the bolus, is 120 mg intravenously. d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy. - <<< ANSWER d Alteplase is a thrombolytic which dissolves clots and can cause bleeding as an adverse effect. Clients who are already taking an anticoagulant or antiplatelet agent are at risk for bleeding and therefore they are not candidates for alteplase therapy. A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse's first action? a. Perform a comprehensive pain assessment. b. Discontinue the infusion of the drug. c. Conduct a neurologic assessment. d. Administer an antihypertensive drug. - <<< ANSWER b A severe headache may indicate that the client's blood pressure has markedly increased and, therefore, the drug should be stopped immediately as the first action. The nurse would then perform the appropriate assessments and possibly administer an antihypertensive medication. A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met? a. Chooses preferred items from the menu. b. Eats 75 to 100% of all meals and snacks. c. Has clear lung sounds on auscultation.
d. Gains 2 lb (1 kg) after 1 week. - <<< ANSWER c Impaired swallowing can lead to aspiration and then aspiration pneumonia, so the expected outcome for this problem is to experience no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate that the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration. A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client's nutritional needs. Which response by the nurse is appropriate? a. "He is NPO until the speech-language pathologist performs a swallowing evaluation." b. "You may give him a full-liquid diet, but please avoid solid foods until he gets stronger." c. "Just be sure to add some thickener in his liquids to prevent choking and aspiration." d. "Be sure to sit him up when you are feeding him to make him feel more natural." - <<< ANSWER a Any client who has or is suspected of having a stroke should have nothing by mouth until he or she is evaluated for any swallowing problem by the speech-language pathologist (SLP). If dysphagia is present, the SLP makes specific recommendations for the client's plan of care which all staff members must follow to prevent choking and aspiration/aspiration pneumonia. A client is admitted with a diagnosis of cerebellar stroke. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform postvoid residuals. - <<< ANSWER a The client who has a cerebellar stroke would be expected to have ataxia, an abnormal gait. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding. A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk for a stroke? a. A 27-year-old heavy-cocaine user.
b. A 30-year-old who drinks a beer a day. c. A 40-year-old who uses seasonal antihistamines. d. A 65-year-old who is active and on no medications. - <<< ANSWER a Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this person uses them seasonally and there is no information that they are abused or used heavily. The 65 year old has only age as a risk factor. The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client? a. Projectile vomiting b. Dilated and nonreactive pupils c. Severe hypertension d. Decreased level of consciousness - <<< ANSWER d The earliest sign of increasing ICP is decreased level of consciousness. The other signs occur later. A client is admitted with a traumatic brain injury. What is the nurse's priority assessment? a. Complete neurologic assessment b. Comprehensive pain assessment c. Airway and breathing assessment d. Functional assessment - <<< ANSWER c Although the client has a brain injury, the most important assessment is to assess the client's ABCs, which includes airway, breathing, and circulation. The other assessments are performed later after the client is stabilized. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse that this is expected and he or she will have to learn to cope. - <<< ANSWER a Personality and behavior often change permanently after head injury. The nurse will explain
this to the spouse. Asking the client about his or her behavior isn't useful because the patient probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles his or her concerns and feelings. The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first? a. Client with amnesia for the incident b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg and on a ventilator d. Client who has a temperature of 102° F (38.9° C) - <<< ANSWER d A fever is a poor prognostic indicator in patients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia for the incident are all either expected or positive findings. A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate? a. Request a directive form the client's primary health care provider. b. Ask the family if they agree to organ donation for the client. c. Wait until brain death is determined before acting on organ donation. d. Contact the local organ procurement organization as soon as possible. - <<< ANSWER d The appropriate nursing action is to respect the client's desire to be an organ donor and contact the local organ procurement organization even if family members do not agree. In most agencies, the primary health care provider does not have to write an order or directive to approve the organ donation. Family consent is not required. After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes, acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first? a. Assess the client's urinary output. b. Assess the client's serum sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour. - <<< ANSWER b This client has signs and symptoms of hypernatremia, which is a possible complication after
craniotomy. The nurse would assess the client's serum sodium level first and then possibly increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results. A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process? a. Cardiac dysrhythmias b. Loss of consciousness c. Nausea and vomiting d. Fever - <<< ANSWER a Due to fluid and electrolyte changes that typically occur during the rewarming process, the nurse monitors for cardiac dysrhythmias. The other findings are not common during this process. A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct? a. "Increased pressure from the tumor can cause seizures." b. "Preventing febrile seizures with a tumor is important." c. "Seizures always occur in clients with brain tumors." d. "This drug is used to sedate with a brain tumor." - <<< ANSWER a Brain tumors can lead to seizures as a complication. The nurse would explain this to the spouse. Preventing febrile seizures is not related to a tumor. Seizures are possible but do not always occur in clients with brain tumors. This drug is not used for sedation. The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a stroke for which the nurse would assess for this client? (Select all that apply.) a. Heavy alcohol intake b. Diabetes mellitus c. Elevated cholesterol d. Obesity e. Smoking f. Hypertension - <<< ANSWER a b c d e f The leading causes of stroke include all of these factors.