NR 464 Final Exam questions with complete solutions, Exams of Nursing

Download NR 464 Final Exam questions with complete solutions and more Exams Nursing in PDF only on Docsity! NR 464 - Exam 3 questions with complete solutions 2024 The jnurse jprovides jhome jcare jinstructions jto ja jclient jwith jsystemic jlupus jerythematosus jand jtells jthe jclient jabout jmethods jto jmanage jfatigue. jWhich jstatement jby jthe jclient jindicates ja jneed jfor jfurther jinstruction? 1. j"I jshould jtake jhot jbaths jbecause jthey jare jrelaxing." 2. j"I jshould jsit jwhenever jpossible jto jconserve jmy jenergy." 3. j"I jshould javoid jlong jperiods jof jrest jbecause jit jcauses jjoint jstiffness." 4. j"I jshould jdo jsome jexercises, jsuch jas jwalking, jwhen jI jam jnot jfatigued." j- jANS✓✓-1. j"I jshould jtake jhot jbaths jbecause jthey jare jrelaxing." To jhelp jreduce jfatigue jin jthe jclient jwith jsystemic jlupus jerythematosus, jthe jnurse jshould jinstruct jthe jclient jto jsit jwhenever jpossible, javoid jhot jbaths j(because jthey jexacerbate jfatigue), jschedule jmoderate jlow-impact jexercises jwhen jnot jfatigued, jand jmaintain ja jbalanced jdiet. jThe jclient jis jinstructed jto javoid jlong jperiods jof jrest jbecause jit jpromotes jjoint jstiffness. The jnurse jis jassisting jin jplanning jcare jfor ja jclient jwith ja jdiagnosis jof jimmunodeficiency jand jshould jincorporate jwhich jaction jas ja jpriority jin jthe jplan? 1. jProtecting jthe jclient jfrom jinfection 2. jProviding jemotional jsupport jto jdecrease jfear 3. jEncouraging jdiscussion jabout jlifestyle jchanges 4. jIdentifying jfactors jthat jdecreased jthe jimmune jfunction j- jANS✓✓-1. jProtecting jthe jclient jfrom jinfection The jclient jwith jacquired jimmunodeficiency jsyndrome jis jdiagnosed jwith jcutaneous jKaposi's jsarcoma. jBased jon jthis jdiagnosis, jthe jnurse junderstands jthat jthis jhas jbeen jconfirmed jby jwhich jfinding? 1. jSwelling jin jthe jgenital jarea 2. jSwelling jin jthe jlower jextremities 3. jPositive jpunch jbiopsy jof jthe jcutaneous jlesions 4. jAppearance jof jreddish-blue jlesions jnoted jon jthe jskin j- jANS✓✓-3. jPositive jpunch jbiopsy jof jthe jcutaneous jlesions Kaposi's jsarcoma jlesions jbegin jas jred, jdark jblue, jor jpurple jmacules jon jthe jlower jlegs jthat jchange jinto jplaques. jThese jlarge jplaques julcerate jor jopen jand jdrain. jThe jlesions jspread jby jmetastasis jthrough jthe jupper jbody jand jthen jto jthe jface jand joral jmucosa. jThey jcan jmove jto jthe jlymphatic jsystem, jlungs, jand jgastrointestinal jtract. jLate jdisease jresults jin jswelling jand jpain jin jthe jlower jextremities, jpenis, jscrotum, jor jface. jDiagnosis jis jmade jby jpunch jbiopsy jof jcutaneous jlesions jand jbiopsy jof jpulmonary jand jgastrointestinal jlesions. The jhome jcare jnurse jis jpreparing jto jvisit ja jclient jwho jhas jundergone jrenal jtransplantation. jThe jnurse jdevelops ja jplan jof jcare jthat jincludes jmonitoring jthe jclient jfor jsigns jof jacute jgraft jrejection. jThe jnurse jdocuments jin jthe jplan jto jassess jthe jclient jfor jwhich jsigns jof jacute jgraft jrejection? 1. jFever, jhypotension, jand jpolyuria 2. jHypertension, jpolyuria, jand jthirst 3. jFever, jhypertension, jand jgraft jtenderness 4. jHypotension, jgraft jtenderness, jand jhypothermia j- jANS✓✓-3. jFever, jhypertension, jand jgraft jtenderness A jclient jwith jacquired jimmunodeficiency jsyndrome j(AIDS) jhas jbeen jstarted jon jtherapy jwith jzidovudine. jThe jnurse jshould jmonitor jthe jresults jof jwhich jlaboratory jblood jstudy jfor jadverse jeffects jof jtherapy? 1. jCreatinine jlevel 2. jPotassium jconcentration 3. jComplete jblood jcell j(CBC) jcount 4. jBlood jurea jnitrogen j(BUN) jlevel j- jANS✓✓-3. jComplete jblood jcell j(CBC) jcount Acquired jimmunodeficiency jsyndrome jis ja jviral jdisease jcaused jby jthe jhuman jimmunodeficiency jvirus j(HIV), jwhich jdestroys jT jcells, jthereby jincreasing 3. jMake jsure jthe jpillow jhas ja jplastic jcover. 4. jKeep ja jchange jof jbed jlinens jnearby jin jcase jthey jare jneeded. For jclients jwith jAIDS jwho jexperience jnight jfever jand jnight jsweats, jthe jnurse jmay joffer jthe jclient jan jantipyretic jof jchoice jbefore jthe jclient jgoes jto jsleep jrather jthan jwaiting juntil jthe jclient jspikes ja jtemperature. jKeeping ja jchange jof jbed jlinens jand jnight jclothes jnearby jfor juse jalso jis jhelpful. jThe jpillow jshould jhave ja jplastic jcover, jand ja jtowel jmay jbe jplaced jover jthe jpillowcase jif jdiaphoresis jis jprofuse. jThe jclient jshould jhave jliquids jat jthe jbedside jto jdrink. A jclient jwith jacquired jimmunodeficiency jsyndrome j(AIDS) jis jexperiencing jnausea jand jvomiting. jThe jnurse jshould jinclude jwhich jmeasure jin jthe jdietary jplan? 1. jProvide jlarge, jnutritious jmeals. 2. jServe jfoods jwhile jthey jare jhot. 3. jAdd jspices jto jfood jfor jadded jflavor. 4. jRemove jdairy jproducts jand jred jmeat jfrom jthe jmeal. j- jANS✓✓-4. jRemove jdairy jproducts jand jred jmeat jfrom jthe jmeal. A jtest jfor jthe jpresence jof jrheumatoid jfactor jis jperformed jin ja jclient jwith ja jdiagnosis jof jrheumatoid jarthritis j(RA). jWhat jresult jshould jthe jnurse janticipate jin jthe jpresence jof jthis jdisease? 1. jNeutropenia 2. jHyperglycemia 3. jAntigens jof jimmunoglobulin jA j(IgA) 4. jUnusual jantibodies jof jthe jIgG jand jIgM jtype j- jANS✓✓-4. jUnusual jantibodies jof jthe jIgG jand jIgM jtype Rheumatoid jarthritis jis ja jchronic, jprogressive, jsystemic jinflammatory jautoimmune jdisease jprocess jthat jaffects jprimarily jthe jsynovial jjoints. jThe jtest jfor jrheumatoid jfactor jdetects jthe jpresence jof junusual jantibodies jof jthe jIgG jand jIgM jtype, jwhich jdevelop jin ja jnumber jof jconnective jtissue jdiseases. jThe jother joptions jare jincorrect. A jcomplete jblood jcell jcount jis jperformed jon ja jclient jwith jsystemic jlupus jerythematosus j(SLE). jThe jnurse jsuspects jthat jwhich jfinding jwill jbe jreported jwith jthis jblood jtest? 1. jIncreased jneutrophils 2. jIncreased jred jblood jcell jcount 3. jIncreased jwhite jblood jcell jcount 4. jDecreased jnumbers jof jall jcell jtypes j- jANS✓✓-4. jDecreased jnumbers jof jall jcell jtypes In jthe jclient jwith jSLE, ja jcomplete jblood jcell jcount jcommonly jshows jpancytopenia, ja jdecrease jin jall jcell jtypes. jThis jprobably jis jcaused jby ja jdirect jattack jon jall jblood jcells jor jbone jmarrow jby jimmune jcomplexes. jThe jother joptions jare jincorrect. The jnurse jis jreviewing jthe jhealth jcare jrecord jof ja jclient jwith ja jnew jdiagnosis jof jrheumatoid jarthritis j(RA). jThe jnurse jshould jrecognize jthat jwhich jare jearly jclinical jmanifestations jof jthis jdisorder? jSelect jall jthat japply. 1. jFatigue 2. jAnorexia 3. jHigh jfever 4. jWeight jloss 5. jGeneralized jweakness j- jANS✓✓-1. jFatigue 2. jAnorexia 5. jGeneralized jweakness Early jmanifestations jof jRA jinclude jfatigue, janorexia, jgeneralized jweakness, jlow-grade jfever, jparesthesias. jWeight jloss jis jone jof jthe jlate jmanifestations. The jnurse jis jcaring jfor ja jclient jwith jacquired jimmunodeficiency jsyndrome j(AIDS) jwho jhas jbegun jto jexperience jmultiple jopportunistic jinfections. jWhich jlaboratory jtest jwould jbe jmost jhelpful jin jassessing jthe jclient's jneed jfor jreassessment jof jtreatment? 1. jWestern jblot 2. jB jlymphocyte jcount 3. jCD4+ jcell jor jT jlymphocyte jcount 4. jEnzyme-linked jimmunosorbent jassay j(ELISA) j- jANS✓✓-3. jCD4+ jcell jor jT jlymphocyte jcount The jT jlymphocyte jor jCD4+ jcell jcount jindicates jwhether jthe jclient jis jresponding jto jthe jmedication jtreatment. jThe jcount jshould jincrease jif jthe jclient jis jresponding jand jshould jdecrease jif jthe jclient's jresponse jis jpoor. jThe jWestern jblot jand jELISA jare jtests jto jassist jin jdiagnosing jhuman jimmunodeficiency jvirus jinfection. jThe jB jlymphocyte jcount jis jnot ja jpriority jmarker jto jmonitor jwith jAIDS jclients. A jclient jwith jacquired jimmunodeficiency jsyndrome jhas jbeen jstarted jon jtherapy jwith jzidovudine. jThe jnurse jassesses jthe jcomplete jblood jcell j(CBC) jcount, jknowing jthat jwhich jis jan jadverse jeffect jof jthis jmedication? 1. jPolycythemia 2. jLeukocytosis 3. jThrombocytosis 4. jAgranulocytopenia j- jANS✓✓-4. jAgranulocytopenia A jclient jis jsuspected jof jhaving jsystemic jlupus jerythematosus j(SLE). jOn jreviewing jthe jclient's jrecord, jthe jnurse jshould jexpect jto jnote jdocumentation jof jwhich jcharacteristic jsign jof jSLE? 1. jFever 2. jFatigue 3. jSkin jlesions 4. jElevated jred jblood jcell jcount j- jANS✓✓-3. jSkin jlesions The jmajor jskin jmanifestation jof jSLE jis ja jdry, jscaly, jraised jrash jon jthe jface jknown jas jthe jbutterfly jrash. jFever jand jfatigue jmay joccur jbefore jand jduring jexacerbation, jbut jthese jsigns jand jsymptoms jare jvague. jAnemia jis jmost jlikely jto joccur jin jSLE. The jhome jcare jnurse jprovides jinstructions jto ja jclient jwith jsystemic jlupus jerythematosus j(SLE) jabout jhome jcare jmeasures. jWhich jstatements jby jthe jclient jindicate jthe jneed jfor jfurther jinstruction? jSelect jall jthat japply. 4. j"It jdetermines jthe jpresence jof jHIV jantibodies jin jthe jbloodstream." j- jANS✓✓- 1. j"It jestablishes jthe jstage jof jHIV jinfection." A jCD4 jT-cell jcount jis jmeasured jin ja jclient jnewly jdiagnosed jwith jhuman jimmunodeficiency jvirus j(HIV). jIn jplanning jcare, jthe jnurse junderstands jthat jwhich jis jaccurate jregarding jthe jCD4 jT-cell jcount? jSelect jall jthat japply. 1. jFalls jin jresponse jto ja jdeclining jviral jload 2. jIs ja jprimary jmarker jof jimmunocompetence 3. jPlays ja jrole jin jthe jcell-mediated jimmune jresponse 4. jIs ja jdirect jmeasure jof jthe jmagnitude jof jHIV jreplication 5. jGuides jdecision jmaking jregarding jtiming jof jinitiation jof jtreatment j- jANS✓✓- 2. jIs ja jprimary jmarker jof jimmunocompetence 3. jPlays ja jrole jin jthe jcell-mediated jimmune jresponse 5. jGuides jdecision jmaking jregarding jtiming jof jinitiation jof jtreatment A jclient jwith jhuman jimmunodeficiency jvirus j(HIV) jinfection jhas ja jfever, jand jhistoplasmosis jis jsuspected. jThe jnurse jshould jprepare jthe jclient jfor jwhich jdiagnostic jtest jto jconfirm jthe jpresence jof jhistoplasmosis? 1. jSkin jbiopsy 2. jSputum jculture 3. jWestern jblot jtest 4. jUpper jgastrointestinal jseries j- jANS✓✓-2. jSputum jculture The jnurse jreviews jthe jrecord jof ja jclient jwith jacquired jimmunodeficiency jsyndrome j(AIDS) jand jnotes jthat jthe jclient jhas ja jdiagnosis jof jCandida. jWhen jperforming jhistory-taking jand jassessment, jwhich jfinding jshould jthe jnurse janticipate? 1. jHyperactive jbowel jsounds 2. jComplaints jof jwatery jdiarrhea 3. jRed jlesions jon jthe jupper jarms 4. jYellowish-white, jcurdlike jpatches jin jthe joral jcavity j- jANS✓✓-4. jYellowish- white, jcurdlike jpatches jin jthe joral jcavity The jnurse jis jassigned jto jcare jfor ja jclient jwith jhuman jimmunodeficiency jvirus j(HIV) jinfection. jThe jnurse jreviews jthe jclient's jhealth jcare jrecord jand jnotes jdocumentation jof jtoxoplasmosis jencephalitis. jOn jthe jbasis jof jthis jinformation, jthe jnurse jwould jassess jfor jwhich jmanifestation? 1. jLesions jon jthe jskin 2. jMental jstatus jchanges 3. jChanges jin jbowel jpattern 4. jLesions jon jthe joral jmucosa j- jANS✓✓-2. jMental jstatus jchanges A jrheumatoid jfactor jassay jis jperformed jin ja jclient jwith ja jsuspected jdiagnosis jof jrheumatoid jarthritis j(RA). jWhich jlaboratory jresult jshould jthe jnurse janticipate? 1. jThe jpresence jof jinflammation 2. jThe jpresence jof jinfection jin jthe jbody 3. jThe jpresence jof jantigens jof jimmunoglobulin jA j(IgA) 4. jThe jpresence jof junusual jantibodies jof jthe jIgG jand jIgM jtypes j- jANS✓✓-4. jThe jpresence jof junusual jantibodies jof jthe jIgG jand jIgM jtypes An jerythrocyte jsedimentation jrate j(ESR) jdetermination jis jprescribed jfor ja jclient jwith ja jconnective jtissue jdisorder. jThe jclient jasks jthe jnurse jabout jthe jpurpose jof jthe jtest. jWhat jshould jthe jnurse jtell jthe jclient jabout jthe jpurpose jof jthe jtest? 1. jDetermines jthe jpresence jof jantigens 2. jIdentifies jwhich jadditional jtests jneed jto jbe jperformed 3. jConfirms jthe jdiagnosis jof ja jconnective jtissue jdisorder 4. jConfirms jthe jpresence jof jinflammation jor jinfection jin jthe jbody j- jANS✓✓-4. jConfirms jthe jpresence jof jinflammation jor jinfection jin jthe jbody A jcomplete jblood jcell j(CBC) jcount jis jperformed jin ja jclient jwith jsystemic jlupus jerythematosus j(SLE). jThe jnurse jwould jsuspect jthat jwhich jfinding jwill jbe jnoted jin jthe jclient jwith jSLE? 1. jDecreased jplatelets jonly 2. jIncreased jred jblood jcell jcount 3. jIncreased jwhite jblood jcell jcount 4. jDecreased jnumber jof jall jcell jtypes j- jANS✓✓-4. jDecreased jnumber jof jall jcell jtypes The jnurse jis jreviewing jthe jhealth jcare jrecord jof ja jclient jwith ja jnew jdiagnosis jof jrheumatoid jarthritis j(RA). jThe jnurse junderstands jthat jwhich jis jan jearly jclinical jmanifestation jof jRA? 1. jAnemia 2. jAnorexia 3. jAmenorrhea 4. jNight jsweats j- jANS✓✓-2. jAnorexia A jclient jwith jacquired jimmunodeficiency jsyndrome j(AIDS) jis jexperiencing jfatigue. jThe jnurse jshould jplan jto jteach jthe jclient jwhich jstrategy jto jconserve jenergy jafter jdischarge jfrom jthe jhospital? 1. jBathe jbefore jeating jbreakfast. 2. jSit jfor jas jmany jactivities jas jpossible. 3. jStand jin jthe jshower jinstead jof jtaking ja jbath. 4. jGroup jall jtasks jto jbe jperformed jearly jin jthe jmorning. j- jANS✓✓-2. jSit jfor jas jmany jactivities jas jpossible. A jclient jwith jacquired jimmunodeficiency jsyndrome j(AIDS) jhas ja jrespiratory jinfection jfrom jPneumocystis jjiroveci jand jhas jbeen jexperiencing jdifficulty jbreathing jand jresultant jproblems jwith jgas jexchange. jWhich jfinding jindicates jthat jthe jexpected joutcome jof jcare jhas jyet jto jbe jachieved? 1. jThe jclient jlimits jfluid jintake. 2. jThe jclient jhas jclear jbreath jsounds. 3. jThe jclient jexpectorates jsecretions jeasily. 1. jBlowing jthe jnose 2. jIsometric jexercises 3. jCoughing jvigorously 4. jExhaling jduring jrepositioning j- jANS✓✓-4. jExhaling jduring jrepositioning A jclient jhas jclear jfluid jleaking jfrom jthe jnose jfollowing ja jbasilar jskull jfracture. jWhich jfinding jwould jalert jthe jnurse jthat jcerebrospinal jfluid jis jpresent? 1. jFluid jis jclear jand jtests jnegative jfor jglucose. 2. jFluid jis jgrossly jbloody jin jappearance jand jhas ja jpH jof j6. 3. jFluid jclumps jtogether jon jthe jdressing jand jhas ja jpH jof j7. 4. jFluid jseparates jinto jconcentric jrings jand jtests jpositive jfor jglucose. j- jANS✓✓-4. jFluid jseparates jinto jconcentric jrings jand jtests jpositive jfor jglucose. A jclient jwith ja jspinal jcord jinjury jis jprone jto jexperiencing jautonomic jdysreflexia. jThe jnurse jshould jinclude jwhich jmeasures jin jthe jplan jof jcare jto jminimize jthe jrisk jof joccurrence? jSelect jall jthat japply. 1. jKeeping jthe jlinens jwrinkle-free junder jthe jclient 2. jPreventing junnecessary jpressure jon jthe jlower jlimbs 3. jLimiting jbladder jcatheterization jto jonce jevery j12 jhours 4. jTurning jand jrepositioning jthe jclient jat jleast jevery j2 jhours 5. jEnsuring jthat jthe jclient jhas ja jbowel jmovement jat jleast jonce ja jweek j- jANS✓✓-1. jKeeping jthe jlinens jwrinkle-free junder jthe jclient 2. jPreventing junnecessary jpressure jon jthe jlower jlimbs 4. jTurning jand jrepositioning jthe jclient jat jleast jevery j2 jhours The jnurse jis jevaluating jthe jneurological jsigns jof ja jclient jin jspinal jshock jfollowing jspinal jcord jinjury. jWhich jobservation jindicates jthat jspinal jshock jpersists? 1. jHyperreflexia 2. jPositive jreflexes 3. jFlaccid jparalysis 4. jReflex jemptying jof jthe jbladder j- jANS✓✓-3. jFlaccid jparalysis Resolution jof jspinal jshock jis joccurring jwhen jthere jis jreturn jof jreflexes j(especially jflexors jto jnoxious jcutaneous jstimuli), ja jstate jof jhyperreflexia jrather jthan jflaccidity, jand jreflex jemptying jof jthe jbladder. The jnurse jhas jjust jadmitted jto jthe jnursing junit ja jclient jwith ja jbasilar jskull jfracture jwho jis jat jrisk jfor jincreased jintracranial jpressure. jPending jspecific jhealth jcare jprovider jprescriptions, jthe jnurse jshould jsafely jplace jthe jclient jin jwhich jpositions? jSelect jall jthat japply. 1. jHead jmidline 2. jNeck jin jneutral jposition 3. jHead jof jbed jelevated j30 jto j45 jdegrees 4. jHead jturned jto jthe jside jwhen jflat jin jbed 5. jNeck jand jjaw jflexed jforward jwhen jopening jthe jmouth j- jANS✓✓-1. jHead jmidline 2. jNeck jin jneutral jposition 3. jHead jof jbed jelevated j30 jto j45 jdegrees The jnurse jin jthe jneurological junit jis jcaring jfor ja jclient jwho jwas jin ja jmotor jvehicle jcrash jand jsustained ja jblunt jhead jinjury. jOn jassessment jof jthe jclient, jthe jnurse jnotes jthe jpresence jof jbloody jdrainage jfrom jthe jnose. jWhich jnursing jaction jis jmost jappropriate? 1. jInsert jnasal jpacking. 2. jDocument jthe jfindings. 3. jContact jthe jhealth jcare jprovider j(HCP). 4. jMonitor jthe jclient's jblood jpressure jand jcheck jfor jsigns jof jincreased jintracranial jpressure. j- jANS✓✓-3. jContact jthe jhealth jcare jprovider j(HCP). Bloody jor jclear jdrainage jfrom jeither jthe jnasal jor jthe jauditory jcanal jafter jhead jtrauma jcould jindicate ja jcerebrospinal jfluid jleak. jThe jappropriate jnursing jaction jis jto jnotify jthe jHCP, jbecause jthis jfinding jrequires jimmediate jintervention. jThe jremaining joptions jare jinappropriate jnursing jactions jin jthis jsituation. The jnurse jis jtrying jto jhelp jthe jfamily jof jan junconscious jclient jcope jwith jthe jsituation. jWhich jintervention jshould jthe jnurse jplan jto jincorporate jinto jthe jcare jroutine jfor jthe jclient jand jfamily? 1. jDiscouraging jthe jfamily jfrom jtouching jthe jclient 2. jExplaining jequipment jand jprocedures jon jan jongoing jbasis 3. jEnsuring jadherence jto jvisiting jhours jto jensure jthe jclient's jrest 4. jEncouraging jthe jfamily jnot jto j"give jin" jto jtheir jfeelings jof jgrief j- jANS✓✓-2. jExplaining jequipment jand jprocedures jon jan jongoing jbasis Members jof jthe jfamily jof jan junconscious jclient jwith jincreased jintracranial jpressure jare jtalking jat jthe jclient's jbedside. jThey jare jdiscussing jthe jclient's jcondition jand jwondering jwhether jthe jclient jwill jever jrecover. jThe jnurse jintervenes jon jthe jbasis jof jwhich jinterpretation? 1. jIt jis jpossible jthe jclient jcan jhear jthe jfamily. 2. jThe jfamily jneeds jimmediate jcrisis jintervention. 3. jThe jclient jmight jhave jwanted ja jvisit jfrom jthe jhospital jchaplain. 4. jThe jfamily jcould jbenefit jfrom ja jconference jwith jthe jhealth jcare jprovider. j- jANS✓✓-1. jIt jis jpossible jthe jclient jcan jhear jthe jfamily. The jnurse jis jcaring jfor ja jclient jwho jhas jundergone ja jcraniotomy jand jhas ja jsupratentorial jincision. jThe jnurse jshould jplace jthe jclient jin jwhich jposition jpostoperatively? 1. jHead jof jbed jflat, jhead jand jneck jmidline 2. jHead jof jbed jflat, jhead jturned jto jthe jnonoperative jside 3. jHead jof jbed jelevated j30 jto j45 jdegrees, jhead jand jneck jmidline 4. jHead jof jbed jelevated j30 jto j45 jdegrees, jhead jturned jto jthe joperative jside j- jANS✓✓-3. jHead jof jbed jelevated j30 jto j45 jdegrees, jhead jand jneck jmidline After jsupratentorial jsurgery, jthe jhead jis jkept jat ja j30- jto j45-degree jangle. jThe jhead jand jneck jshould jnot jbe jangled jeither janteriorly jor jlaterally jbut jrather jshould jbe jkept jin ja jneutral j(midline) jposition. jThis jpromotes jvenous jreturn 1. jGiving jtepid jsponge jbaths 2. jApplying ja jhypothermia jblanket 3. jCovering jthe jclient jwith jblankets 4. jAdministering jacetaminophen jper jprotocol 5. jPlacing jice jpacks jover jthe jclient's jabdomen jand jin jthe jaxilla jand jgroin j- jANS✓✓-1. jGiving jtepid jsponge jbaths 2. jApplying ja jhypothermia jblanket 4. jAdministering jacetaminophen jper jprotocol The jnurse jis jadministering jmouth jcare jto jan junconscious jclient. jThe jnurse jshould jperform jwhich jactions jin jthe jcare jof jthis jperson? jSelect jall jthat japply. 1. jUse jproducts jthat jcontain jalcohol. 2. jPosition jthe jclient jon jhis jor jher jside. 3. jBrush jthe jteeth jwith ja jsmall, jsoft jtoothbrush. 4. jCleanse jthe jmucous jmembranes jwith jsoft jsponges. 5. jUse jlemon jglycerin jswabs jwhen jperforming jmouth jcare. j- jANS✓✓-2. jPosition jthe jclient jon jhis jor jher jside. 3. jBrush jthe jteeth jwith ja jsmall, jsoft jtoothbrush. 4. jCleanse jthe jmucous jmembranes jwith jsoft jsponges. The jnurse jassigned jto jthe jcare jof jan junconscious jclient jis jmaking jinitial jdaily jrounds. jOn jentering jthe jclient's jroom, jthe jnurse jobserves jthat jthe jclient jis jlying jsupine jin jbed, jwith jthe jhead jof jthe jbed jelevated japproximately j5 jdegrees. jThe jnasogastric jtube jfeeding jis jrunning jat j70 jmL/hr, jas jprescribed. jThe jnurse jassesses jthe jclient jand jauscultates jadventitious jbreath jsounds. jWhich jjudgment jshould jthe jnurse jformulate jfor jthe jclient? 1. jImpaired jnutritional jintake 2. jIncreased jrisk jfor jaspiration 3. jIncreased jlikelihood jfor jinjury 4. jSusceptibility jto jfluid jvolume jdeficit j- jANS✓✓-2. jIncreased jrisk jfor jaspiration The jnurse jis jcaring jfor ja jclient jwith ja jhead jinjury. jThe jclient's jintracranial jpressure jreading jis j8 jmm jHg. jWhich jcondition jshould jthe jnurse jdocument? 1. jThe jintracranial jpressure jreading jis jnormal. 2. jThe jintracranial jpressure jreading jis jelevated. 3. jThe jintracranial jpressure jreading jis jborderline. 4. jAn jintracranial jpressure jreading jof j8 jmm jHg jis jlow j- jANS✓✓-1. jThe jintracranial jpressure jreading jis jnormal. The jnurse jin jthe jneurological junit jis jmonitoring ja jclient jfor jsigns jof jincreased jintracranial jpressure j(ICP). jThe jnurse jreviews jthe jassessment jfindings jfor jthe jclient jand jnotes jdocumentation jof jthe jpresence jof jCushing's jreflex. jThe jnurse jdetermines jthat jthe jpresence jof jthis jreflex jis jobtained jby jassessing jwhich jitem? 1. jBlood jpressure 2. jMotor jresponse 3. jPupillary jresponse 4. jLevel jof jconsciousness j- jANS✓✓-1. jBlood jpressure The jnurse jis jdeveloping ja jplan jof jcare jfor jan jolder jclient jthat jaddresses jinterventions jto jprevent jcold jdiscomfort jand jthe jdevelopment jof jaccidental jhypothermia. jThe jnurse jshould jdocument jwhich jdesired joutcome jin jthe jplan jof jcare? 1. jThe jclient's jfingers jand jtoes jare jcool jto jtouch. 2. jThe jclient's jbody jtemperature jis j98°F j(36.7°C). 3. jThe jclient jremains jin ja jfetal jposition jwhen jin jbed. 4. jThe jclient jcomplains jof jcoolness jin jthe jhands jand jfeet jonly. j- jANS✓✓-2. jThe jclient's jbody jtemperature jis j98°F j(36.7°C). The jnurse jin jthe jneurological junit jis jcaring jfor ja jclient jwith ja jsupratentorial jlesion. jThe jnurse jassesses jwhich jmeasurement jas jthe jmost jcritical jindex jof jcentral jnervous jsystem j(CNS) jdysfunction? 1. jTemperature 2. jBlood jpressure 3. jAbility jto jspeak 4. jLevel jof jconsciousness j- jANS✓✓-4. jLevel jof jconsciousness The jnurse jis jcaring jfor ja jclient jafter ja jcraniotomy jand jmonitors jthe jclient jfor jsigns jof jincreased jintracranial jpressure j(ICP). jWhich jfinding, jif jnoted jin jthe jclient, jwould jindicate jan jearly jsign jof jincreased jICP? 1. jConfusion 2. jBradycardia 3. jSluggish jpupils 4. jA jwidened jpulse jpressure j- jANS✓✓-1. jConfusion The jnurse jis jcaring jfor ja jclient jwho jsustained ja jspinal jcord jinjury. jDuring jadministration jof jmorning jcare, jthe jclient jbegins jto jexhibit jsigns jand jsymptoms jof jautonomic jdysreflexia. jWhich jinitial jnursing jaction jshould jthe jnurse jtake? 1. jElevate jthe jhead jof jthe jbed. 2. jExamine jthe jrectum jdigitally. 3. jAssess jthe jclient's jblood jpressure. 4. jPlace jthe jclient jin jthe jprone jposition. j- jANS✓✓-1. jElevate jthe jhead jof jthe jbed. The jhome jcare jnurse jis jmaking ja jvisit jto ja jclient jwho jrequires juse jof ja jwheelchair jafter ja jspinal jcord jinjury jsustained j4 jmonths jearlier. jJust jbefore jleaving jthe jhome, jthe jnurse jensures jthat jwhich jintervention jhas jbeen jdone jto jprevent jan jepisode jof jautonomic jdysreflexia j(hyperreflexia)? 1. jUpdating jthe jhome jsafety jsheet 2. jLeaving jthe jclient jin jan junchilled jarea jof jthe jroom 3. jNoting ja jbowel jmovement jon jthe jclient jprogress jnote 1. jPaO2 j60 jto j100 jmm jHg j(60 jto j100 jmm jHg), jPaCo2 j25 jto j30 jmm jHg j(25 jto j30 jmm jHg) 2. jPaO2 j60 jto j100 jmm jHg j(60 jto j100 jmm jHg), jPaCo2 j30 jto j35 jmm jHg j(30 jto j35 jmm jHg) 3. jPaO2 j80 jto j100 jmm jHg j(80 jto j100 jmm jHg), jPaCo2 j25 jto j30 jmm jHg j(25 jto j30 jmm jHg) 4. jPaO2 j80 jto j100 jmm jHg j(80 jto j100 jmm jHg), jPaCo2 j35 jto j38 jmm jHg j(35 jto j38 jmm jHg) j- jANS✓✓-4. jPaO2 j80 jto j100 jmm jHg j(80 jto j100 jmm jHg), jPaCo2 j35 jto j38 jmm jHg j(35 jto j38 jmm jHg) The jnurse jis jproviding jcare jto ja jclient jwith jincreased jintracranial jpressure j(ICP). jWhich japproach jis jbeneficial jin jcontrolling jthe jclient's jICP jfrom jan jenvironmental jviewpoint? 1. jReduce jenvironmental jnoise. 2. jAllow jvisitors jas jdesired jby jthe jclient jand jfamily. 3. jAwaken jthe jclient jevery j2 jto j3 jhours jto jmonitor jmental jstatus. 4. jCluster jnursing jactivities jto jreduce jthe jnumber jof jinterruptions. j- jANS✓✓-1. jReduce jenvironmental jnoise. The jhome jcare jnurse jis jmaking jextended jfollow-up jvisits jto ja jclient jdischarged jfrom jthe jhospital jafter ja jmoderately jsevere jhead jinjury. jThe jfamily jstates jthat jthe jclient jis jbehaving jdifferently jthan jbefore jthe jaccident. jThe jclient jis jmore jfatigued jand jirritable jand jhas jsome jmemory jproblems. jThe jclient, jwho jwas jpreviously jvery jeven jtempered, jis jprone jto joutbursts jof jtemper jnow. jThe jnurse jdetermines jthat jthese jbehaviors jare jindicative jof jwhich jproblem? 1. jIntracranial jpressure jchanges 2. jA jlong-term jsequela jof jthe jinjury 3. jA jworsening jof jthe joriginal jinjury 4. jA jshort-term jproblem jthat jwill jresolve jin jabout j1 jmonth j- jANS✓✓-2. jA jlong- term jsequela jof jthe jinjury A jclient jwas jseen jand jtreated jin jthe jhospital jemergency jdepartment jfor ja jconcussion. jThe jnurse jdetermines jthat jthe jfamily jneeds jfurther jteaching jif jthey jverbalize jto jcall jthe jhealth jcare jprovider j(HCP) jfor jwhich jclient jsign jor jsymptom? 1. jVomiting 2. jMinor jheadache 3. jDifficulty jspeaking 4. jDifficulty jawakening j- jANS✓✓-2. jMinor jheadache A jclient jwith ja jspinal jcord jinjury jexpresses jlittle jinterest jin jfood jand jis jvery jparticular jabout jthe jchoice jof jmeals jthat jare jactually jeaten. jHow jshould jthe jnurse jinterpret jthis jinformation? 1. jAnorexia jis ja jsign jof jclinical jdepression, jand ja jreferral jto ja jpsychologist jis jneeded. 2. jThe jclient jhas jcompulsive jhabits jthat jshould jbe jignored jas jlong jas jthey jare jnot jharmful. 3. jThe jclient jprobably jhas ja jnaturally jslow jmetabolism, jand jthe jdecreased jnutritional jintake jwill jnot jmatter. 4. jMeal jchoices jrepresent jan jarea jof jclient jcontrol jand jshould jbe jencouraged jas jmuch jas jis jnutritionally jreasonable. j- jANS✓✓-4. jMeal jchoices jrepresent jan jarea jof jclient jcontrol jand jshould jbe jencouraged jas jmuch jas jis jnutritionally jreasonable. The jnurse jis jteaching ja jclient jwith jparaplegia jmeasures jto jmaintain jskin jintegrity. jWhich jinstruction jwill jbe jmost jhelpful jto jthe jclient? 1. jShift jweight jevery j2 jhours jwhile jin ja jwheelchair. 2. jChange jbed jsheets jevery jother jweek jto jmaintain jcleanliness. 3. jPlace ja jpillow jon jthe jseat jof jthe jwheelchair jto jprovide jextra jcomfort. 4. jUse ja jmirror jto jinspect jfor jredness jand jskin jbreakdown jtwice ja jweek. j- jANS✓✓-1. jShift jweight jevery j2 jhours jwhile jin ja jwheelchair. A jclient jwith ja jtraumatic jbrain jinjury jis jable, jwith jeyes jclosed, jto jidentify ja jset jof jkeys jplaced jin jhis jor jher jhands. jOn jthe jbasis jof jthis jassessment jfinding, jthe jnurse jdetermines jthat jthere jis jappropriate jfunction jof jwhich jlobe jof jthe jbrain? 1. jFrontal 2. jParietal 3. jOccipital 4. jTemporal j- jANS✓✓-2. jParietal A jclient jhas jsuffered ja jhead jinjury jaffecting jthe joccipital jlobe jof jthe jbrain. jWhat jis jthe jfocus jof jthe jnurse's jimmediate jassessment? 1. jTaste 2. jSmell 3. jVision 4. jHearing j- jANS✓✓-3. jVision A jclient jhas ja jhigh jlevel jof jcarbon jdioxide j(CO2) jin jthe jbloodstream, jas jmeasured jby jarterial jblood jgases. jThe jnurse janticipates jthat jwhich junderlying jpathophysiology jcan joccur jas ja jresult jof jthis jelevated jCO2? 1. jIt jwill jcause jarteriovenous jshunting. 2. jIt jwill jcause jvasodilation jof jblood jvessels jin jthe jbrain. 3. jIt jwill jcause jblood jvessels jin jthe jcircle jof jWillis jto jcollapse. 4. jIt jwill jcause jhyperresponsiveness jof jblood jvessels jin jthe jbrain. j- jANS✓✓-2. jIt jwill jcause jvasodilation jof jblood jvessels jin jthe jbrain. A jclient jis janxious jabout jan jupcoming jdiagnostic jprocedure. jThe jclient's jpupils jare jdilated, jand jthe jrespiratory jrate, jheart jrate, jand jblood jpressure jare jincreased jfrom jbaseline. jThe jnurse jdetermines jthat jthe jclient's jclinical jmanifestations jare jdue jto jwhat jtype jof jphysiologic jresponse? 1. jVagal 2. jPeripheral jnervous jsystem 3. jSympathetic jnervous jsystem 4. jParasympathetic jnervous jsystem j- jANS✓✓-3. jSympathetic jnervous jsystem To jpromote joptimal jcerebral jtissue jperfusion jin jthe jpostoperative jphase jfollowing jcranial jsurgery, jthe jnurse jshould jplace jthe jclient jwith jan jincision jin jthe janterior jor jmiddle jfossa, jin jwhich jposition? 2. jHyperoxygenating jbefore jsuctioning 3. jMaintaining j20 jdegree jflexion jof jthe jknees 4. jMaintaining jthe jhead jand jneck jin jmidline jposition 5. jMaintaining jthe jhead jof jthe jbed j(HOB) jat j30 jdegrees jelevation j- jANS✓✓-2. jHyperoxygenating jbefore jsuctioning 4. jMaintaining jthe jhead jand jneck jin jmidline jposition 5. jMaintaining jthe jhead jof jthe jbed j(HOB) jat j30 jdegrees jelevation The jnurse jis jcaring jfor jthe jclient jwho jsuffered ja jspinal jcord jinjury j48 jhours jago. jWhat jshould jthe jnurse jassess jfor jwhen jmonitoring jfor jgastrointestinal jcomplications? 1. jA jhistory jof jdiarrhea 2. jA jflattened jabdomen 3. jHyperactive jbowel jsounds 4. jHematest-positive jnasogastric jtube jdrainage j- jANS✓✓-4. jHematest-positive jnasogastric jtube jdrainage The jclient jwith ja jspinal jcord jinjury jat jthe jlevel jof jT4 jis jexperiencing ja jsevere jthrobbing jheadache jwith ja jblood jpressure jof j180/100 jmm jHg. jWhat jis jthe jpriority jnursing jintervention? 1. jNotify jthe jhealth jcare jprovider j(HCP). 2. jLoosen jtight jclothing jon jthe jclient. 3. jPlace jthe jclient jin ja jsitting jposition. 4. jCheck jthe jurinary jcatheter jtubing jfor jkinks jor jobstruction. j- jANS✓✓-3. jPlace jthe jclient jin ja jsitting jposition. The jnurse jis jpositioning ja jclient jwho jhas jincreased jintracranial jpressure. jWhich jposition jshould jthe jnurse javoid? 1. jHead jmidline 2. jHead jturned jto jthe jside 3. jNeck jin jneutral jposition 4. jHead jof jbed jelevated j30 jto j45 jdegrees j- jANS✓✓-2. jHead jturned jto jthe jside A jpostoperative jcraniotomy jclient jwho jsustained ja jsevere jhead jinjury jis jadmitted jto jthe jneurological junit. jWhat jnursing jintervention jis jnecessary jfor jthis jclient? 1. jTake jand jrecord jvital jsigns jevery j4 jto j8 jhours. 2. jProphylactically jhyperventilate jduring jthe jfirst j24 jhours. 3. jTreat ja jcentral jfever jwith jthe jadministration jof jantipyretic jmedications jsuch jas jacetaminophen. 4. jKeep jthe jhead jof jthe jbed jelevated jat jleast j30 jdegrees, jand jposition jthe jclient jto javoid jextreme jflexion jor jextension jof jthe jneck jand jhead. j- jANS✓✓-4. jKeep jthe jhead jof jthe jbed jelevated jat jleast j30 jdegrees, jand jposition jthe jclient jto javoid jextreme jflexion jor jextension jof jthe jneck jand jhead. The jnurse jis jassessing ja jclient's jmuscle jstrength jand jnotes jthat jwhen jasked, jthe jclient jcannot jmaintain jthe jhands jin ja jsupinated jposition jwith jthe jarms jextended jand jeyes jclosed. jHow jshould jthe jnurse jcorrectly jdocument jthis jfinding jon jthe jmedical jrecord? 1. jClient jis jdemonstrating jataxia. 2. jClient jis jexhibiting jpronator jdrift. 3. jClient jappears jto jhave jnystagmus. 4. jClient jexamination jreveals jhyperreflexia. j- jANS✓✓-2. jClient jis jexhibiting jpronator jdrift. The jnurse jis jplanning jto jperform jan jassessment jof jthe jclient's jlevel jof jconsciousness jusing jthe jGlasgow jComa jScale. jWhich jassessments jshould jthe jnurse jinclude jin jorder jto jcalculate jthe jscore? jSelect jall jthat japply. 1. jEye jopening 2. jReflex jresponse 3. jBest jverbal jresponse 4. jBest jmotor jresponse 5. jPupil jsize jand jreaction j- jANS✓✓-1. jEye jopening 3. jBest jverbal jresponse 4. jBest jmotor jresponse A jclient jwith ja jtraumatic jclosed jhead jinjury jshows jsigns jof jsecondary jbrain jinjury. jWhat jare jsome jmanifestations jof jsecondary jbrain jinjury? jSelect jall jthat japply. 1. jFever 2. jSeizures 3. jHypoxia 4. jIschemia 5. jHypotension 6. jIncreased jintracranial jpressure j(ICP) j- jANS✓✓-3. jHypoxia 4. jIschemia 5. jHypotension 6. jIncreased jintracranial jpressure j(ICP) Secondary jbrain jinjury jcan joccur jseveral jhours jto jdays jafter jthe jinitial jbrain jinjury jand jis ja jmajor jconcern jwhen jmanaging jbrain jtrauma. jNursing jmanagement jof jthe jclient jwith jan jacute jintracranial jproblem jmust jinclude jmanagement jof jsecondary jinjury. jManifestations jof jsecondary jinjury jincludes jhypoxia, jischemia, jhypotension, jand jincreased jICP jthat jfollows jprimary jinjury. jIt jdoes jnot jinclude jfever jor jseizures.