NR 325 Final EXAM QUESTIONS AND VERIFIED ANSWERS (GRADED A+), Exams of Nursing

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NR 325 Final EXAM QUESTIONS AND

VERIFIED ANSWERS (GRADED A+)

The nurse is caring for a patient who had a tonic clonic seizure. Which of the following is most concerning? Vomiting The nurse is caring for a patient with a ruptured cerebral aneurysm. Which of the following should be immediately reported to the healthcare provider? Select all that apply. 1 episode of small amount of vomiting Confusion Intracranial pressure 19mmHg Ataxia The nurse is caring for a patient with epilepsy who takes phenytoin. Which of the following should the nurse include in the patient education? Select all that apply. Practice oral care and floss regularly Anticipate regular blood draws This medication can cause a slow heart rate The nurse is caring for a patient with vascular dementia who is agitated and demanding to leave the facility to go Christmas shopping. Which of the following statements by the nurse is most appropriate? Tell me about who you shop for at Christmas The nurse in a long-term care facility is providing education to a group of caregivers for people with early stages of dementia. Which of the following would be included in the education Bring in pictures of family members It is important for the caregivers to practice self-care Provide referrals for adult daycare Provide referrals to case management The nurse is caring for a patient who presents with a thunderclap headache and states "This is the worst headache of my life" which of the following nursing actions is most important. elevate the head of the bed 30 degrees The nurse is caring for a patient with an embolic stroke in the left hemisphere. The nurse anticipates which of the following symptoms? Speech and language problems The nurse is caring for a patient who developed dysarthria and confusion. The nurse should take which of the following actions? Obtain a blood glucose Call a code stroke Complete a BEFAST assessment

Anticipate a CT head scan The nurse is caring for a patient with a history of epilepsy. Which of the following nursing interventions should the nurse include Place a pad on the floor next to the bed Ensure suction is available Have a bag-valve mask and oxygen available The nurse is caring for a paraplegic patient with a spinal cord injury at T8. The patient appears flushed and diaphoretic and complains of sudden onset of a severe headache. The nurse should assess for which of the following complications? Autonomic dysreflexia The nurse is caring for a patient with multiple sclerosis who was admitted for an exacerbation of symptoms. Which of the following complications is a priority to monitor for? Respiratory depression The nurse is caring for a patient with Parkinson's disease. Which of the following medications will help to control the motor symptoms associated with this disease? Carbidopa/Levodopa The nurse is caring for a patient with late stage Alzheimer's Disease. Which of the following are considered manifestations of late Alzheimer's disease? Select all that apply Incontinence Dysphagia Aphasia The nurse is caring for a patient who abuses alcohol. The nurse suspects that patient has developed hepatic encephalopathy when they exhibit which of the following symptoms. Asterixis The nurse is caring for a patient with hepatic encephalopathy. Who is prescribed lactulose. The nurse knows this medication is effective when Patient has 3-4 loose bowel movements daily The nurse is caring for a patient with severe left upper quadrant pain and a positive Turner sign. Which of the following orders is anticipated? Lactated ringers Morphine 2mg IV push Amylase Pantoprazole 80mg IV push The nurse is caring for patient who is being discharged after a laparoscopic cholecystectomy. Which of the statements made by the patient requires further education? I will eat a low-fat, nutrient dense diet for about 1 week after Surgery

The nurse in the PACU is caring for a patient who had an endoscopic retrograde cholangiopanreatography (ERCP). Which of the following should be immediately reported to the provider? Sudden and severe abdominal pain The nurse is caring for a patient diagnosed with acute hepatitis B. Which of the following statements made by the patient indicates a need for further teaching? It is safe for me to take acetaminophen for pain The nurse is caring for a patient with end-stage cirrhosis. Which of the following should be included in the nursing plan of care? Lactulose Proton pump inhibitor Use a soft bristle tooth brush daily weights fall precautions measure abdominal girth Use a sitter Which of the following is considered a risk factor for cholecystitis? Advanced age Pregnancy The nurse is caring for a patient who is scheduled for a transurethral resection of the prostate (TURP). Which of the following statements made by the patient requires further education? Immediately after surgery, I may experience urinary incontinence The nurse is providing care for a patient who is scheduled for a papanicolaou (PAP) test. Which of the following statements made by the patient demonstrates understanding? I will have this test done every 3 years for cervical cancer A woman with a family history of breast cancer is attending a routine mammogram screening. During the examination, a suspicious mass is detected. The healthcare provider orders a breast biopsy to further investigate the findings. The patient expresses anxiety about the procedure. Which statement made by the patient requires clarification? "I am worried the biopsy will spread the cancer to other parts of my body." Which of the following is not considered a risk for breast cancer? Late menarche The nurse is providing education for a patient who had a mastectomy 20 years ago and now has lymphedema. Which of the following should be included in the patient education? A JP drain will be used to reduce fluid accumulation in the arm Which of the following patients is at greatest risk for development of colorectal cancer A 52 year-old Black male with a BMI 32 The nurse is caring for a patient with leukemia. Which of the following lab results is anticipated? Select all that apply WBC 22, Platelet 70,

The nurse is providing education to a patient and their family about the use of chemotherapy to treat acute lymphocytic leukemia (ALL). Which of the following statements demonstrates understanding? I can use salt water rinses or ice water to help with soreness in my mouth The nurse is caring for a patient who was just told they have stage 4 breast cancer. Which of the following statements made by the nurse is most appropriate? Tell me about how you are feeling The nurse is caring for an elderly patient who was just admitted to hospice care for stage 4 breast cancer. Which statement made by the family requires additional clarification? The nurse will administer opioid pain medication that will eventually stop her breathing Which of the following is true of hospice care? A patient can choose to revoke or be discharged from hospice care at anytime A 70-year-old patient with advanced metastatic cancer has been referred to palliative care. The nurse is educating the family about the principles of palliative care. Which statement by the family member indicates a need for further clarification? Once in palliative care, we can no longer pursue aggressive medical interventions Which assessment finding indicated that the client had a stroke? Select all that apply. Lopsided smile Unilateral vision Incoherent speech Unable to raise right arm Symptoms started two hours ago Which behavior would the nurse include when teaching a family what to expect from a client who has experienced a stroke on the left side of the brain? Select all that apply. Slow performance and caution Impaired speech/language aphasia Awareness of deficits with depression and anxiety When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumo Having suction available during meals Which goal would the nurse include in the plan of care to address dysarthria in a client after a stroke? Effective communicat Which is the priority nursing action for a client admitted to the hospital in a coma after having a stroke? Maintain an open airway.

Which explanation would the nurse provide to a client about transient ischemic attacks (TIAs)? Temporary episodes of neurological dysfunction Which task will be difficult for a client admitted to the hospital with the diagnosis of a right-sided cerebrovascular accident (CVA) who is righthanded? Dressing every morning Which clinical finding in a child with a diagnosis of meningitis indicates an increase in intracranial pressure? Select all that apply. One, some, or all responses may be correct. Irritability Bradycardia During a follow-up visit, the nurse finds increased intracranial pressure in a client who has undergone nasal hypophysectomy for hyperpituitarism. Which action taken by the client is responsible for this condition? Blowing the nose and sneezing Which clinical finding is consistent with an increase in intracranial pressure? Lowered level of consciousness The diagnostic reports of a client who underwent a hypophysectomy indicate an intracranial pressure (ICP) of 20 mm Hg. Which action made by the client is responsible for the reported ICP? Bending over at the waist Which position would the nurse place a client in during the immediate period after injury to the frontal lobe of the brain? Low-Fowler Which intervention would the nurse perform first for the client admitted with a closed head injury and increased intracranial pressure (ICP)? Place the head and neck in neutral alignment. Which complication would the nurse assess in both clients who have Parkinson disease and clients who have myasthenia gravis? Difficulty swallowing Which action will the nurse take to support cognitive ability in clients who have Alzheimer disease? Select all that apply. One, some, or all responses may be correct. Encouraging caregivers to support safe independence Using calendars, clocks, and pictures to support memory Providing a limited number of choices to support decision-making Which intervention will the nurse include in a care plan for a client with Alzheimer disease? Select all that apply. One, some, or all responses may be correct. Limit choices. Toilet every 2 hours. Encourage participation in self-care.

Which finding would indicate that a client needs to be evaluated by the health care provider for Alzheimer disease (AD)? Forgets home address Which nursing action is most important for a client with urinary retention related to benign prostatic hyperplasia who has a secondary diagnosis of delirium related to urosepsis and a prescription for the insertion of an indwelling urinary retention catheter? Determine whether any unsafe behavior patterns exist. Which characteristic mental change occurs with delirium and differentiates it from dementia? Rapid-onset confusion In which position would the nurse place a client with a spinal cord injury experiencing autonomic dysreflexia? High Fowler Which assessment is the priority after checking airway for a client with a cervical spinal cord injury? Level of consciousness Which factor would the nurse consider as a possible cause when caring for a client with signs of autonomic hyperreflexia? Distended large intestine Which nursing action is appropriate for a patient during the tonic-clonic stage of a seizure? Protect the client's head from injury Which piece of equipment will the nurse remove from the bedside of a client on seizure precautions? Padded tongue blade Which question is most useful when planning nursing care for a client who has a tonic- clonic seizure at work and is admitted to the emergency department? "Were you aware of anything different or unusual just before your seizure began?" After the nurse has finished teaching methods of reducing fatigue to the client with multiple sclerosis, which statement made by the client indicates that the client has understood the nurse ' s instruction? Rest in an air-conditioned room Which nursing intervention would the nurse implement for a hospitalized client with multiple sclerosis who voices a concern about generalized weakness and fluctuating physical status? Space activities throughout the day. Which response would the nurse make to a client recently diagnosed with multiple sclerosis who says, "I had planned to get married, but after this diagnosis, I might not be ready."? "You don't feel able to make a decision at this time?" Which intervention will the nurse include in a care plan for a client with dementia who wanders? Select all that apply. One, some, or all responses may be correct. Assess and treat pain. Avoid loud music, television, and glaring lights.

Have family members monitor client activity when possible. Which information would the nurse include in the teaching plan for a client diagnosed with epilepsy? The client will take anticonvulsant medications for life. Which clinical indicator would the nurse review before scheduling a client for an endoscopic retrograde cholangiopancreatography (ERCP)? Bilirubin level A client has laparoscopic surgery to remove a calculus from the common bile duct. Which postoperative client response indicates to the nurse that bile flow into the duodenum is reestablished? Stools become brown. The assessment of a newly admitted client reveals malnourishment, nausea, distension, and a firm abdomen with ascites. The client has tachycardia and is hypotensive. Which physiological change occurred that resulted in the client's development of ascites? A decrease in plasma protein to maintain adequate capillary-tissue circulation Which statement by the client recovering from an acute case of viral hepatitis indicates understanding of the discharge instructions presented by the nurse? Select all that apply. One, some, or all responses may be correct. The nurse provides education for a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions would be included in the teaching plan? Select all that apply. One, some, or all responses may be correct Screening of blood donors Maintaining a monogamous sexual relationship A client with a long history of alcohol use is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority? Institute fall prevention and safety measures The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which is appropriate to include in the client's dietary plan? Reduced fat intake to avoid stimulation of the cholecystokinin mechanism for bile release The nurse is assessing female clients and identifies that which client has the greatest risk of developing gallbladder disease? Older than age 40 and obese When the nurse is caring for a client who had an open cholecystectomy, which assessment finding most indicates the need for action by the nurse? Decreased breath sounds at lung bases The nurse is caring for a client after a laparoscopic cholecystectomy. Which nursing action is priority? Assess puncture sites for bleeding.

A client with Laënnec cirrhosis experiences ascites, jaundice, and confusion. Which is a nursing priority when caring for this client? Providing for the client's physical safety A client had a laparoscopic cholecystectomy. Postoperatively, the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What would the nurse include in the teaching plan when preparing this client for discharge? Select all that apply. One, some, or all responses may be correct. Call the health care provider for a fever of 100°F (37.8°C) or higher more for 2 days. Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage. A client is hospitalized with a diagnosis of acute pancreatitis. The plan of care is focused on the goals of maintaining nutrition, promoting rest, maintaining fluids and electrolytes, and decreasing anxiety. Which interventions would the nurse implement? Select all that apply. One, some, or all responses may be correct Administer analgesics Teach relaxation exercises Monitor cardiac rate and rhythm The nurse reviews the laboratory results of a client with acute pancreatitis. Which test is significant in determining the client's response to treatment? Amylase level A client is hospitalized with acute pancreatitis. Which would be included in the client's plan of care? Use intravenous (IV) fluids. For which sign of hepatic encephalopathy would the nurse assess a client with cirrhosis of the liver? Select all that apply. One, some, or all responses may be correct. Mental confusion Flapping hand tremors Musty, sweet breath odor Which assessment finding would the nurse expect to observe in a client with severe liver disease? Icterus A client with jaundice associated with hepatitis expresses concern over the change in skin color. Which does the nurse explain is the cause of this color change? Inability of the liver to remove normal amounts of bilirubin from the blood A client is diagnosed as having the hepatitis B virus (HBV). The nurse reviews the client's health history for situations in which exposure may have occurred. Which event does the nurse determine is most likely the source of this infection? The client received a small tattoo on the arm 3 months ago The nurse teaches a client who is concerned about hepatitis transmission routes. Which type of hepatitis spreads more frequently through food? Hepatitis A A client with cholelithiasis is scheduled for a lithotripsy. Which would the nurse include in the client's teaching plan? Opioids will be available for postprocedural pain.

Which response would the nurse provide to a client who asks about what to expect postoperatively before a transurethral resection of the prostate (TURP)? "There will be a urinary catheter and a continuous bladder irrigation." Which nursing action would the nurse monitor during the initial recovery phase of a client returning to the postanesthesia care unit with a three-way indwelling catheter and a continuous bladder irrigation after a transurethral prostatectomy (TURP)? Monitor for bright red blood in the urinary drainage bag. Which response would the nurse give to a client who had a transurethral resection of the prostate (TURP) who experiences dribbling after removal of the indwelling catheter? "Increase your fluid intake and urinate at regular intervals." Which information about benign prostatic hyperplasia (BPH) is important for the nurse to consider when caring for a client with that condition? It predisposes to hydronephrosis. Which condition would the nurse suspect in a client who complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination with a digital rectal examination report indicating smooth, firm, and enlarged prostate tissue surrounding the urethra? Benign prostatic hyperplasia (BPH) Which test result would confirm the diagnosis of benign prostatic hyperplasia (BPH)? Biopsy of prostatic tissue Which clinical manifestation would indicate the cancer is in an early stage in a male client with a preliminary diagnosis of cancer of the urinary bladder? Hematuria Which goal is the nurse trying to achieve with continuous bladder irrigations (CBI) of a client who has undergone a suprapubic prostatectomy for cancer of the prostate? Prevent the development of clots in the bladder. Which factor would a nurse suspect as the likely cause in a client with cancer of the prostate who requests the urinal frequently but either does not void or voids in very small amounts? Retention What information from a client' s history would the nurse identify as risk factors for the development of colon cancer? Select all that apply. One, some, or all responses may be correct. Increased age Ulcerative colitis Which response would the nurse offer when a client undergoing brachytherapy for breast cancer asks what precautions need to be observed? Visitors should be limited, particularly pregnant women and children."

Which stage of syphilis is the client experiencing when there are not any clinical manifestations? Latent Which action would the nurse implement when assessing a client with a new diagnosis of syphilis? Select all that apply. One, some, or all responses may be correct Ask the client about medication allergies Examine the client's lymph nodes for enlargement. Gather information about any ulcers or rashes. Ask about the client's sexual activity and protection methods During which time period after contracting syphilis could the infection be transmitted to others? 2 years Which sexually transmitted infection is managed with antiviral medications as the treatment of choice? Genital herpes Which medication would the nurse expect to administer when caring for a client who is diagnosed with syphilis? Penicillin G Which response would the nurse at the community clinic provide to a client recently diagnosed with syphilis who is hesitant to share the names and locations of those with whom they had sexual relations because of fear of retribution? "If you give us a list, we will contact them. We will not be identifying you as the source." Which service provided by the public health nurse through the local health department would support primary prevention of human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct Provide information about safe- sex practices through local venues. Support community level initiatives to impact traditions, norms, and beliefs regarding sexuality. Which intervention would the nurse implement to prevent cross contamination of herpes genitalis from one client to another? Wear a gown and gloves when providing direct care. Which response would a nurse give to a female client with cancer of the breast admitted for lumpectomy to be followed by radiation who, while being admitted to ambulatory surgery by the nurse, has tears in her eyes and in a shaky voice says, "I can't believe this is happening "? "This must be a very scary time for you." A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up? "I will use an oatmeal-based lotion after each treatment. Which client statement indicates a risk of breast cancer? Select all that apply. One, some, or all responses may be correct "My first child was born when I was 32."

"I noticed a slight discharge from a nipple." "I consume two to four glasses of alcohol a day Which factor identified in a client's history places her at increased risk for breast cancer? Advanced maternal-age with first pregnancy A 28-year-old woman is diagnosed as having cancer of the left breast. A simple mastectomy is performed. Which action would be included in the plan of care immediately after surgery? Placing the client in the semi-Fowler position with the left arm elevated Which intervention would the nurse include when teaching a client about self-care after mastectomy to prevent infection and lymphedema? Select all that apply.One, some, or all responses may be correct. Wear gloves when gardening. Apply a compression sleeve if edema occurs. Consider learning exercises for manual lymph drainage. Avoid blood draws in the arm on the side of the mastectomy. Which clinical findings would the nurse anticipate when assessing a child with newly diagnosed acute lymphoblastic leukemia? Select all that apply. One, some, or all responses may be correct. Pallor Fatigue Multiple bruises Which nursing intervention would the nurse implement when providing care for pediatric clients with leukemia on chemotherapeutic protocols? Having them avoid contact with infected persons Which action would the nurse take regarding the new prescription of a client who is receiving methotrexate for acute lymphocytic leukemia (ALL) and develops a temperature of 101°F (38.3°C) after the health care provider prescribes aspirin 650 mg every 4 hours as needed? Express concern about the type of antipyretic prescribed. Which nursing action would be included in the plan of care when a client is admitted with thrombocytopenia? Select all that apply. One, some, or all responses may be correct. Avoid intramuscular injections. Examine the skin for ecchymotic areas. Which intervention will be beneficial for the safe and effective care of a hospitalized immunosuppressed client? Select all that apply. One, some, or all responses may be correct. Avoid using supplies from common areas. Encourage activity at an appropriate level. Use alcohol-based hand rubs before touching the client. Which action would a nurse take to avoid complications in a client who has developed severe bone marrow depression after receiving chemotherapy for cancer? Select all

that apply. One, some, or all responses may be correct. Wash hands before entering the client's room. Advise use of a soft toothbrush for oral hygiene. Report an elevation in temperature immediately How can the nurse best manage a common side effect of chemotherapy? Providing meticulous oral hygiene An adolescent with leukemia is to be given a chemotherapeutic agent. Which time is best for the nurse to administer the prescribed antiemetic? Before each dose of chemotherapy A client is experiencing stomatitis as a result of chemotherapy. Which action would the nurse take when caring for this client? Provide frequent saline mouthwashes. Three months after beginning chemotherapy, a client develops severe anorexia, stomatitis, and episodes of diarrhea. Goals for the client are to increase caloric intake and decrease the pain associated with stomatitis. To address the goals, which activity would the nurse include in the plan of care? Suck on an ice pop every 2 hours. What information from a client' s history would the nurse identify as risk factors for the development of colon cancer? Select all that apply. One, some, or all responses may be correct Increased age Ulcerative colitis The nurse provides postoperative teaching about colostomy care to a client who underwent surgery for cancer of the colon. The education would include which instruction related to skin care around the stoma? Wash the area with soap and water and then apply a protective ointment. The nurse reviews the medical record of a client who is eligible to receive hospice care. Which are the criteria for a client to receive this type of care? Select all that apply. One, some, or all responses may be When the death of the client is imminent When the expected death of the client is within 6 months When the client has been issued a "do not resuscitate" order Which information regarding palliative care as opposed to hospice care would the nurse provide during a home visit to a client with heart failure who asks about this option? The focus of palliative care is to enhance you and your family's quality of life despite your heart failure. Which intervention would the home health care nurse who visits an older adult couple living independently implement knowing that the wife cares for the husband, who has dementia? Select all that apply. One, some, or all responses may be correct.

Which interventions would the nurse perform while caring for an actively dying client? Select all that apply. One, some, or all responses may be correct. Provide client and family reassurance. Offer symptom management to the client. The student nurse is describing palliative care to a client's family. Which statement made by the student nurse indicates a need for correction by the registered nurse (RN)? "Palliative care is the same as hospice care." The nurse is educating the caregivers of an elderly adult with advanced Parkinson disease about continuing care. Which information would the nurse provide? Select all that apply. One, some, or all responses may be correct. "Adult day care centers are ideal for clients whose caregivers have to be away from home during the day." "Hospice care is a continuing care system that allows terminal clients to live at home with comfort, independence, and dignity." "Nursing centers provide 24-hour custodial care to help residents achieve and maintain their highest level of functioning." Which situation accurately describes hospice care? System of family-centered care that allows clients to remain at home in comfort while easing the pains of terminal illness Which nursing interventions enhance comfort in a dying client in the hospital? Select all that apply. One, some, or all responses may be correct. Frequently repositioning the client Maintaining oral hygiene in the client Applying body lotion to the client's skin daily The nurse is caring for clients who are in the terminal stage of illness. The nurse begins feeling depressed when coming to work. Which would the nurse do? Talk with other nurses on the unit. Which action will the nurse take when caring for a terminally ill client receiving a morphine drip that exceeds the typical recommended dosage whose spouse tells the nurse that the client is again uncomfortable and needs the morphine increased (The prescription states to titrate the morphine to comfort level)? Assess the client's pain before increasing the dose of morphine. Which statement made by a client with a chlamydial infection indicates an understanding of the potential complications? "I need to treat this infection so it doesn't spread into my pelvis because I want to havechildren someday." Copious amounts of frothy, greenish vaginal discharge would be a symptom of which infection? Trichomoniasis

On a follow-up visit after having a vaginal hysterectomy, a 32-year-old client has an elevated temperature and decreased hematocrit. Which complication does this suggest? Hematoma A nurse enters the room of a client who had a left modified mastectomy 8 hours earlier. Which observation indicates that the nursing assistant assigned to the client needs further instruction and guidance? The client is wearing a robe with elastic cuffs. Which factor in a client's history indicates she's at risk for candidiasis? Use of corticosteroids For which symptom should a client at risk for evisceration be monitored after an abdominal hysterectomy? Low-grade fever with increasing serosanguineous incisional drainage Which factor should be checked when evaluating the effectiveness of an alpha- adrenergic blocker given to a client with benign prostatic hypertrophy (BPH)? Voiding pattern A 27-year-old man arrives at the clinic with priapism. The nurse arranges for an immediate neurologic consult because of the risk of which condition. Penile gangrene Which information should be given to a client taking metronidazole (Flagyl)? Mixing this drug with alcohol causes severe nausea and vomiting. During a routine physical examination, a firm mass is palpated in the right breast of a 35 - year-old female client. Which finding or client history would suggest cancer of the breast as opposed to fibrocystic disease? Increased vascularity of the breast An 80-year-old male client reports urine retention. Which factor may contribute to this client's problem? Benign prostatic hypertrophy Which intervention would be correct for a woman having intracavitary radiation for cancer of the cervix? Bed rest Which statement should be included when teaching a client newly diagnosed with testicular cancer? Testicular self-examination is still important because there's an increased risk for a second tumor. The nurse reads in the medical record that a client's tumor is staged at T2, N0, M0. The nurseconcludes that this staging indicates which of the following about the client's status? The client has a measurable tumor with no indication of metastasis or involvement of nodes. A client with lung cancer is admitted to the oncology clinic to receive radiation therapy for treatment of spinal cord compression. The client's spouse asks why radiation is

being done. The nurse's response would include that radiation therapy is used: To reduce the size of the tumor A new nurse on the unit is admitting a severely leukopenic client who is receiving radiation therapy. The preceptor determines that the new nurse understands precautionary measure snecessary for this client when he admits this client to which of the following rooms? A private room with protective isolation A client newly diagnosed with breast cancer is scheduled for a lymph node biopsy and asks the nurse why it is necessary when a diagnosis of cancer has already been made. The nurse's best response is based on which of the following? A lymph node biopsy is performed to determine if the cancer has metastasized. A 65-year-old postmenopausal client tells the nurse that she has recently experienced painless vaginal bleeding. The nurse should: A client is brought to the surgical unit after a suprapubic prostatectomy. He has a three- wayFoley catheter. The nurse notices a very dark red output via the catheter. What is the appropriate nursing intervention? Increase the irrigation flow rate. A client returns to the medical unit following transurethral resection of the prostate (TURP). The client states to the nurse that he wants the three-way Foley catheter to be removed because it is causing him to have bladder spasms. Which of the following is the best response by a nurse? "Spasms are painful but expected because of the wide diameter of the catheter and theretention balloon in the bladder." While a nurse is discussing a client's likely death with family members, one of the adult children inquires, "We plan on taking turns being here for now, but we all want to be here at the time of death. Is there any way we can tell what that time is close?" Which of the following is the nurse's best response? The arms and legs become more bluish in color and are cool to touch. Breathing willbecome irregular and shallow and will change speed. Call me if you hear mucus in thethroat. The pulse and blood pressure will decrease." The nurse working with a terminally ill client wishes to support the client's decisions concerning end-of-life care. To do this appropriately, the nurse should plan to do which of the following? Respect the client's wishes about death to the extent possible by law The terminally ill client asks the nurse for information about hospice care. The nurse would best respond by stating: Hospice regards dying as a normal part of life and provides support for a dignified and peaceful death." The older adult client diagnosed with Parkinson's disease (PD) has been prescribed the combination medication carbidopa/levodopa. Which data indicates the medication is effective? The client is able to walk upright without stumbling

The client with increased intracranial pressure is receiving mannitol. Which intervention should the nurseimplement to evaluate the effectiveness of the medication? Assess the client's neurological status. Which of the following is a common complication of hemorrhagic stroke? Cerebral edema Hemorrhagic stroke is less common than ischemic stroke. False What is the leading cause of hemorrhagic stroke? Hypertension The term "extravasation" is based on Latin ("extra" refers to being outside something and "vas" refers to vessel). Extravasation is the condition that may happen if fluids spill from IV (intravenous) lines during chemotherapy treatment. True Select appropriate discharge instructions to patient going home post TURP? SATA Prevent constipation by increasing fiber Increase hydration. Avoid colas, caffeine and other irritants such as citrus fruits For a client who has stomatitis post chemotherapy nurse should encourage that the client should use a soft toothbrush and gently brush after each meal to reduce mouth irritation and prevent superinfections. Avoid spicy foods, offer cold beverages. Maintain good hygiene at all times to avoid unnecessary infections. True Select appropriate treatments for acute pancreatitis? Calcium Gluconate to treat hypocalcemia IV Proton pump inhibitors and NG tube Pain management (crucial to manage pain). Antibiotics NPO with IV fluids (hydration). To prevent urinary tract infections and constipation discourage fluids and mobility False Select the correct statements related to HPV. HPV causes most strains of cervical and penile cancer. HPV is the most common STD. Risk factors for Ovarian Cancer? SATA Smoking and obesity Family history of Breast or Ovarian Cancer Early menarche or late menopause Having children later or never having a full-term pregnancy Select manifestations of Ovarian Cancer? Ascites or increase in abdominal girth Indigestion, acid reflux and bloating

Early satiety and change in bowel and bladder habits Post traumatic head injury which of the following signs and symptoms of increased ICP would appear first? Restlessness and confusion Cushing triad is a clinical syndrome consisting of hypertension, bradycardia and irregular respiration and is a sign of impending brain herniation. True Select clinical manifestations of BPH? Dysuria Nocturia Frequency and urgency Urinary retention Weak urine stream or dribbling. Adverse side effects of chemotherapy include Neutropenia due to (myelosuppression) and thrombocytopenia. Chemo destroys all cells: good (platelets and WBCs) and the bad (cancer cells). True A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of: Respiratory or gastrointestinal infection during the previous month Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? Ineffective airway clearance Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? Ataxia and confusion Alpha-adrenergic blockers, such as tamsulosin and doxazosin, work to relax the smooth muscle of the prostate gland, reducing urinary obstruction and improving urine flow. True A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? Urine output increases or LOC improves, or patient is more awake. Patient with Herpes Virus needs to be treated aggressively and immediately with antiviral meds. Antiviral medication shorten the duration of viral shedding, shorten healing time, and reduce the frequency of outbreaks. Educate the client that Herpes is not curable Encourage the client to use a mirror to inspect their lesions. True A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? Time of onset of current stroke

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? Schedule for a STAT computer tomography (CT) scan of the head. What is the biggest risk factor for hemorrhagic stroke? History of uncontrolled HTN Select all the correct treatment for hemorrhagic stroke. Antihypertensive medication. Prepare client for surgery (to evacuate the blood resulting from hemorrhage). Hemorrhagic strokes may cause increased intracranial pressure and seizures. The first sign of hemorrhagic stroke is HEADACHE or changes True What are clinical manifestations of Meningitis? SATA Headache and N/V Positive Kernig's sign. Nuchal rigidity and photosensitivity. Red macular rash Restlessness, irritability and tachycardia Changes in pupils A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? Raise the head of the bed A Glasgow Coma Scale of 8 or less indicates a severe injury that has dramatically affected the person's state of consciousness. Scores between 9 and 12 indicate a moderate injury but are also normal scores in a recovery ward. Minor injuries rarely score less than 13 on a Glasgow Coma Scale assessment. True The nurse should anticipate administering all of the following meds to a client with increased intracranial pressure due to brain hemorrhage Except.? Nitroglycerin Select the factors that can increase delirium? Preexisting conditons. Insomnia Narcotics Delirium is a reversible condition. True Which of the following is a key component of delirium management? Identifying and treating underlying causes The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. The nurse tells the client that this is most effectively done by: Taking medications on time to maintain therapeutic blood levels.

What are the clinical manifestations of Multiple Sclerosis? SATA Blurred vision, diplopia, scotomas Numbness and tingling Unsteady gait and discoordination What factors exacerbate Multiple Sclerosis? SATA Stress Surgery A client with chronic liver failure progresses to Hepatic Encephalopathy? The nurse should expect that the client will have the following manifestations? SATA Elevated ammonia (NH4) Asterixis (Hepatic flap). Fatigue Fetor hepaticus Disorientation progressing to coma. Slurred speech Education to client with seizures? SATA Take meds as prescribed. Therapeutic levels of meds should be drawn per PCP order. Do not mix alcohol with meds. Wear a medic alert all the time. Avoid stress, loud noises and be sensitive to the aura. Select seizures precautions for a client with history of seizures? Pad the bed and place it in the lowest position. Administer antiseizure medications as scheduled. Monitor for side effects, monitor labs. Have suction and oxygen setup in the room. If patient begins to seize, turn the patient on side, protect the head and provide privacy. If seizure continues after five minutes anticipate that PCP will order Ativan or Valium Drip. If a client is diagnosed with Dementia he should be educated about the severity of the disorder and encouraged to make major life decision such as power of authority, end of life decisions. Truev

The nurse is caring for a patient who had a tonic clonic seizure. Which of

the following is most concerning? Vomiting

The nurse is caring for a patient with a ruptured cerebral aneurysm.

Which of the following should be immediately reported to the healthcare

provider? Select all that apply. 1 episode of small amount of vomiting

Confusion

Intracranial pressure 19mmHg

Ataxia

The nurse is caring for a patient with epilepsy who takes phenytoin. Which

of the following should the nurse include in the patient education? Select

all that apply. Practice oral care and floss regularly

Anticipate regular blood draws

This medication can cause a slow heart rate

The nurse is caring for a patient with vascular dementia who is agitated

and demanding to leave the facility to go Christmas shopping. Which of the

following statements by the nurse is most appropriate? Tell me about who

you shop for at Christmas

The nurse in a long-term care facility is providing education to a group of

caregivers for people with early stages of dementia. Which of the

following would be included in the education Bring in pictures of family

members

It is important for the caregivers to practice self-care

Provide referrals for adult daycare

Provide referrals to case management

The nurse is caring for a patient who presents with a thunderclap

headache and states "This is the worst headache of my life" which of the

following nursing actions is most important. elevate the head of the bed

30 degrees

The nurse is caring for a patient with an embolic stroke in the left

hemisphere. The nurse anticipates which of the following symptoms?

Speech and language problems

The nurse is caring for a patient who developed dysarthria and confusion.

The nurse should take which of the following actions? Obtain a blood

glucose

Call a code stroke

Complete a BEFAST assessment

Anticipate a CT head scan

The nurse is caring for a patient with a history of epilepsy. Which of the

following nursing interventions should the nurse include Place a pad on

the floor next to the bed

Ensure suction is available

Have a bag-valve mask and oxygen available

The nurse is caring for a paraplegic patient with a spinal cord injury at T8.

The patient appears flushed and diaphoretic and complains of sudden

onset of a severe headache. The nurse should assess for which of the

following complications? Autonomic dysreflexia

The nurse is caring for a patient with multiple sclerosis who was admitted

for an exacerbation of symptoms. Which of the following complications is

a priority to monitor for? Respiratory depression

The nurse is caring for a patient with Parkinson's disease. Which of the

following medications will help to control the motor symptoms associated

with this disease? Carbidopa/Levodopa

The nurse is caring for a patient with late stage Alzheimer's Disease.

Which of the following are considered manifestations of late Alzheimer's

disease? Select all that apply Incontinence

Dysphagia

Aphasia

The nurse is caring for a patient who abuses alcohol. The nurse suspects

that patient has developed hepatic encephalopathy when they exhibit

which of the following symptoms. Asterixis

The nurse is caring for a patient with hepatic encephalopathy. Who is

prescribed lactulose. The nurse knows this medication is effective when

Patient has 3-4 loose bowel movements daily

The nurse is caring for a patient with severe left upper quadrant pain and

a positive Turner sign. Which of the following orders is anticipated?

Lactated ringers

Morphine 2mg IV push

Amylase

Pantoprazole 80mg IV push

The nurse is caring for patient who is being discharged after a

laparoscopic cholecystectomy. Which of the statements made by the

patient requires further education? I will eat a low-fat, nutrient dense diet

for about 1 week after Surgery

The nurse in the PACU is caring for a patient who had an endoscopic

retrograde cholangiopanreatography (ERCP). Which of the following

should be immediately reported to the provider? Sudden and severe

abdominal pain

The nurse is caring for a patient diagnosed with acute hepatitis B. Which

of the following statements made by the patient indicates a need for

further teaching? It is safe for me to take acetaminophen for pain

The nurse is caring for a patient with end-stage cirrhosis. Which of the

following should be included in the nursing plan of care? Lactulose

Proton pump inhibitor

Use a soft bristle tooth brush

daily weights

fall precautions

measure abdominal girth

Use a sitter

Which of the following is considered a risk factor for cholecystitis?

Advanced age

Pregnancy

The nurse is caring for a patient who is scheduled for a transurethral

resection of the prostate (TURP). Which of the following statements made

by the patient requires further education? Immediately after surgery, I

may experience urinary incontinence

The nurse is providing care for a patient who is scheduled for a

papanicolaou (PAP) test. Which of the following statements made by the

patient demonstrates understanding? I will have this test done every 3

years for cervical cancer

A woman with a family history of breast cancer is attending a routine

mammogram screening. During the examination, a suspicious mass is

detected. The healthcare provider orders a breast biopsy to further

investigate the findings. The patient expresses anxiety about the

procedure. Which statement made by the patient requires clarification? "I

am worried the biopsy will spread the cancer to other parts of my body."

Which of the following is not considered a risk for breast cancer? Late

menarche

The nurse is providing education for a patient who had a mastectomy 20

years ago and now has lymphedema. Which of the following should be

included in the patient education? A JP drain will be used to reduce fluid

accumulation in the arm

Which of the following patients is at greatest risk for development of

colorectal cancer A 52 year-old Black male with a BMI 32

The nurse is caring for a patient with leukemia. Which of the following lab

results is anticipated? Select all that apply WBC 22,000

Platelet 70,000

The nurse is providing education to a patient and their family about the

use of chemotherapy to treat acute lymphocytic leukemia (ALL). Which of

the following statements demonstrates understanding? I can use salt

water rinses or ice water to help with soreness in my mouth

The nurse is caring for a patient who was just told they have stage 4

breast cancer. Which of the following statements made by the nurse is

most appropriate? Tell me about how you are feeling

The nurse is caring for an elderly patient who was just admitted to

hospice care for stage 4 breast cancer. Which statement made by the

family requires additional clarification? The nurse will administer opioid

pain medication that will eventually stop her breathing

Which of the following is true of hospice care? A patient can choose to

revoke or be discharged from hospice care at anytime

A 70-year-old patient with advanced metastatic cancer has been referred

to palliative care. The nurse is educating the family about the principles of

palliative care. Which statement by the family member indicates a need