NU 448-EXAM 4-with 100% verified answers-2024-2025.docx, Exams of Nursing

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NU 448-EXAM 4-with 100% verified

answers-2024-

1. The nurse, on the mental health unit, is caring for a client who has had several verbal outbursts, is pacing around the unit and is at risk for assaultive behavior. Which of the following statements by the nurse would be most appropriate? a. "Please take a time-out in your room."
2. The nurse is planning care for a client with moderate rheumatoid arthritis (RA). Which of the following nonpharmacologic interventions should the nurse include in the client's plan of care? Select all that apply. a. Applying splints to rest inflamed joints, b. Using Velcro fasteners on clothes to aid in dressing, c. Applying moist heat to joints to relax muscles and relieve pain.
3. The nurse is planning care for a client who is newly diagnosed with human immunodeficiency virus (HIV). Which of the following prescribed prophylactic measures should the nurse include in the client's plan of care? Select all that apply. a. Hep B b. Influenza c. pneumococcal vaccines
4. The nurse is planning care for a client who has a recent diagnosis of multiple sclerosis (MS). Which of the following interventions should the nurse include in the client's care plan? a. Encouraged to increase the fiber in his or her diet, void 30 minutes after drinking to help train the bladder and avoid constipation, and participate in daily muscle stretching to help alleviate and relax muscle spasms
5. The nurse is changing the descending colostomy for a client with a history of Crohn's disease. Which of the following findings should be a priority for the nurse to follow up? a. A colostomy stoma should be bright, beefy red and moist. A dark purple-blue dry stoma may indicate compromised circulation or ischemia and a pale stoma can indicate anemia.
6. While performing a genital assessment on a 26-year-old male client, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. Which of the following should the nurse suspect the client is experiencing? a. genital warts
7. The nurse is caring for a client who fell at home and is diagnosed with right hip fracture. Which of the following would be most important for the nurse to assess?

a. neurovascular assessment of the affected leg is always a priority assessment

8. The nurse is planning care for a client in the emergency department (ED) with an open fracture of the radius. The nurse should include which of the following interventions as a priority in the client's plan of care? a. "Risk for infection"
9. The nurse is caring for a client who had a total knee replacement (TKR) and has been placed in a continuous passive motion (CPM) device. The client asks, "What is the purpose of this machine?" The nurse should explain the purpose by telling the client

which of the following? a. to promote a range of motion, circulation, and healing and to prevent scar tissue from forming in the knee 10.The nurse is caring for a client who has just been diagnosed with hemorrhagic stroke. The client's family is asking the nurse for information about the client's condition. Which of the following statements by the nurse would be appropriate? a. Hemorrhagic stroke is bleeding either within the brain or on the surface of the brain. The client with hemorrhagic stroke might require immediate aneurysm clipping and/or evacuation of a hematoma by a neurosurgeon 11.The nurse on the stroke team is working with colleagues to stabilize a client who has just been brought to the hospital with stroke symptoms. Which of the following actions by the unlicensed assistive personnel (UAP) would require intervention by the nurse? a. If the UAP is feeding the client, should be kept NPO 12.The nurse is providing information for the family of a client who had a transient ischemic attack and is scheduled for carotid endarterectomy. Which of the following information would be appropriate for the nurse to give the family? a. To prevent stroke in a client with significant carotid atherosclerosis, carotid endarterectomy may be performed. The procedure involves surgical removal of carotid plaque to improve cerebral perfusion. 13.The nurse is caring for a client who has a subdural hematoma following traumatic head injury. The nurse notes systolic hypertension with widening pulse pressure and bradycardia. Which of the following actions would be appropriate for the nurse to take after notifying the health care provider? a. client prepared for surgical intervention, which might include the evacuation of the hematoma, placement of a catheter for drainage of cerebrospinal fluid, and/or craniectomy (removal of part of the skull). 14.The nurse has assessed a client, who hit their head during a fall, using the Glasgow Coma Scale (GCS) and calculated a score of 6. Which of the following actions would be appropriate for the nurse to take in addition to notifying the health care provider of the GCS score? a. mechanical ventilation b. making the anesthesiology department aware of the client's condition allows them to be prepared for possible intubation 15.The nurse on the stroke team has received a client who is exhibiting signs of stroke and is being transported for a CT scan of the brain. Which of the following information would be the priority for the nurse to try to obtain? a. determining the timing of onset is the single most important piece of information to collect. 16.The nurse on the neurological care unit has received a client who has been diagnosed with subarachnoid hemorrhage. The nurse should be prepared to assist in implementing which of the following potential treatments? Select all that apply.

a. Antihypertensive therapy with an oral or IV agent is the main drug therapy for hemorrhagic stroke. b. Insertion of a ventriculostomy

17.The nurse on the neurological care unit is assessing a client who has a Glasgow Coma Scale score of 3. Which of the following findings is consistent with a GCS score of 3? a. A client who is in a coma is incontinent of urine and feces. 18.The nurse has taught an education conference about antibiotics being prescribed for clients with skull fractures who have rhinorrhea and otorrhea. Which of the following statements by a nurse would indicate a correct understanding of the conference? a. The risk for meningitis is high for this client, so prophylactic antibiotic therapy is initiated 19.The nurse is assessing a client who fell in the hallway and notes the client is exhibiting an altered level of consciousness (LOC) and Battle's sign is present. Which of the following actions would be a priority for the nurse to take? a. prioritize stabilizing the client's cervical spine by supporting the client's neck until a cervical collar is applied. 20.The nurse is caring for a client immediately after receiving a craniotomy with an incision over the middle fossa and notes the client is in a supine position? Which of the following actions would be most appropriate for the nurse to take? a. The nurse should raise the HOB and complete an incident report 21.The nurse is caring for a client with increased intracranial pressure (ICP). The client has a nursing diagnosis of Ineffective cerebral tissue perfusion. Which of the following would be an expected outcome for this client? a. obeying commands with appropriate motor responses. 22.The nurse is caring for a client with increased intracranial pressure (ICP). The nurse observes the client's urine output from the indwelling urethral catheter to be 1,500 milliliters for the last 2 hours. Which of the following should the nurse suspect the client is experiencing? a. Diabetes insipidus 23.The nurse is caring for a client with a traumatic brain injury (TBI) following a fall. Which of the following medications should the nurse anticipate being prescribed for the client to reduce cerebral edema? a. The osmotic diuretic mannitol 24.The nurse is caring for a client with increased intracranial pressure (ICP) who has developed a syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following prescribed interventions should the nurse implement? a. requires fluid restriction and monitoring of serum electrolyte levels. 25.The nurse is caring for a client that has a ventriculostomy for monitoring increased intracranial pressure (ICP). Which of the following would indicate to the nurse that the client is experiencing a complication of the ventriculostomy? a. ventricular infection, meningitis, and problems with the monitoring system. Nuchal rigidity, fever, chills, and photophobia are clinical manifestations of meningitis.

26.The nurse is admitting a 16-year-old client who returned home early from summer camp with fever, severe headache, and vomiting. Which of the following prescribed interventions should the nurse implement first? a. blood cultures should be collected immediately so antibiotic therapy can be

tailored if bacteremia is discovered 27.The nurse is caring for a client who has been diagnosed with acute subdural hematoma after falling at home. Which of the following findings should indicate to the nurse that the client is experiencing a complication? a. increased intracranial pressure., b. ipsilateral (same side as the lesion) pupil dilation and fixation occurs 28.The nurse in an outpatient setting is assessing a client's risk for ischemic stroke. The nurse should assess for which of the following conditions? Select all that apply. a. Diabetes mellitus b. Atrial fibrillation c. Atherosclerotic narrowing of the carotid arteries 29.The nurse is caring for a client who has aphasia following a stroke. Which of the following would facilitate communication with the client? a. asking short, simple questions that can be ended with "yes" or "no." 30.The nurse on the neurological care unit is talking with the spouse of a client who had an ischemic stroke and is having an echocardiogram. The family member says, "I do not understand why the heart is being tested when a stroke affects the brain." Which of the following responses should the nurse make? a. Emboli from the heart can lodge in the cerebral vasculature and cause an ischemic stroke. An echocardiogram can identify this problem, which guides the treatment and prevention of future stroke. 31.The nurse is planning care for a client who has homonymous hemianopsia following a right hemispheric stroke. Which of the following interventions should the nurse include in the client's plan of care? a. the left side of the visual field in both eyes would be absent ( the nurse should remind the client to scan for items on the left side of the plate by rotating the neck to the left). 32.The nurse is caring for a client who had a right hemispheric stroke and has been evaluated by the speech therapist. The client has both motor and visual deficits. During the client's first meal, since having a stroke, which of the following actions should the nurse take? a. the nurse should encourage the client to "double swallow" after each bite to facilitate safe swallowing of food. 33.The nurse has provided information about urinary elimination to the spouse of a client who recently had a stroke. Which of the following statements by the client's spouse would require follow-up by the nurse? a. The use of a long-term indwelling catheter should be avoided because of increased risk for urinary tract infection. 34.The nurse is observing family members care for a client who has multiple deficits following a stroke 2 weeks ago. The nurse must intervene if a family member is observed doing which of the following? a. massaging damaged skin can cause additional damage. 35.The nurse on the neurosurgical unit is receiving a client who has a history

of transient ischemic attacks and had an intracranial stent placed 30 minutes ago. Which of the

following would be a standard post-procedure nursing measure after intracranial stent placement? a. the client must keep his or her leg straight for a period of time. 36.The nurse is providing discharge teaching about post-concussion syndrome for a client and the client's family. The nurse should include in the teaching that the client might experience which of the following? Select all that apply. a. Experiences a persistent headache, a decreased short-term memory, and personality changes 37.The nurse on the neurological care unit is conducting a staff education conference about subdural hematoma. Which of the following information should the nurse include in the conference? a. As the brain atrophies with age, the subdural space becomes larger. The brain remains attached to supportive structures, but since the tension is higher, there is a higher likelihood of tearing and resulting bleeding. 38.The nurse on the neurological care unit is planning a staff education conference about conditions that would require intracranial pressure monitoring with a ventriculostomy. Which of the following conditions should the nurse include in the conference? Select all that apply. a. Subdural hematoma b. Brain tumor c. Encephalitis 39.The nurse is caring for a client who has a ventriculostomy. Which of the following actions by the nurse would be appropriate? a. the transducer must be level with the intraventricular foramen, the reference point for which is the tragus of the ear. 40.The nurse is caring for a client who suffered a skull fracture 6 hours ago and has a positive halo sign, or ring sign. The nurse should recognize that this finding is associated with an increased risk for which of the following? a. the risk for meningitis is high. 41.The nurse is preparing to calculate a client's Glasgow Coma Score. Which of the following actions should the nurse take? a. the nurse tries to elicit a response, such as a flexion withdrawal, to a painful stimulus, such as pressure on the client's proximal nail bed. 42.The nurse is caring for a client who has expressive aphasia following a stroke. The nurse has taught the client's spouse about ways to facilitate communication. Which of the following comments by the client's spouse would require follow-up? a. The client's spouse should not feign understanding because this does not truly facilitate communication. 43.The nurse on the neurological unit is caring for a client who sustained a basilar skull fracture 6 hours ago. The client is awake and oriented. Which of the following remarks by the client should be a priority for the nurse to

follow up? a. client's report of the nose running 44.The nurse caring for a client who has hemiparesis following a right hemispheric stroke has taught the client's spouse ways to help care for the client. Which of the following

actions by the client's spouse would require the nurse to intervene? a. The client should be prompted to lead with his or her strong side (the right side) when transferring from a bed to a wheelchair positioned next to the bed. 45.The nurse on the neurological unit is caring for a client who had a traumatic brain injury. The client's Glasgow Coma Score has changed from 10 to 9, and the client is snoring. Which of the following actions would be appropriate for the nurse to take? a. Removal of accumulated secretions by suctioning b. The nurse should limit each pass to 10 seconds and perform no more than two passes at a time. 46.The nurse on the neurological care unit has reviewed health care provider prescriptions for assigned clients. The nurse should contact the health care provider and clarify which of the following prescriptions? a. Hypertonic saline (not hypotonic saline) is used to decrease intracranial pressure. 47.The nurse on the neurological unit is preparing to receive a client from the emergency department who had an ischemic stroke. The nurse demonstrates appropriate anticipation of the client's potential needs by gathering which of the following? Select all that apply. a. Having suction equipment readily available b. Have a bedpan ready c. Having pads for the side rails of the client's bed d. Kept pt NPO 48.The nurse on the neurological unit is positioning a client who had a stroke two days ago and has left-sided hemiparesis. Which of the following actions by the nurse would be appropriate? Select all that apply. a. Prevention of joint contracture b. Position the client to maintain neutral joint alignment c. A trochanter roll placed lateral to the left hip d. The arm is placed in a sling to prevent subluxation of the shoulder. 49.The nurse in the emergency department has received a client exhibiting manifestations of a stroke, which the client's spouse says began 90 minutes ago. The client's CT scan confirms stroke and ruled out intracranial hemorrhage. Which of the following actions should the nurse take first? a. The nurse must immediately secure intravenous access because fibrinolytic therapy is administered intravenously 50.The nurse in the emergency department receives a client who was transported from prison with high fever, severe headache, and a non- blanchable rash on the trunk and lower extremities. Which of the following actions would be appropriate for the nurse to take, while the staff works to confirm a diagnosis? a. Respiratory isolation 51.The nurse is caring for a group of assigned clients. Which of the following clients should the nurse see first?

a. The client is exhibiting signs of pneumonia which could be life- threatening and should be followed-up with.

52.The nurse has taught a client about the newly prescribed clopidogrel. Which of the following statements, by the client, would indicate a correct understanding of the teaching? a. Clopidogrel is an antiplatelet medication and the client should notify the dentist prior to an appointment because the client is at risk for bleeding. 53.The nurse is planning an education conference about anticoagulation and the direct factor Xa inhibitor medications. Which of the following medications should the nurse include in the conference? Select all that apply. a. Coumadin, which is an anticoagulant b. Rivaroxaban factor Xa inhibitor. c. Apixaban is factor Xa inhibitor. 54.The nurse is planning an education conference about an intravenous anesthetic sedative medication that has a rapid onset, short half-life and is used to manage anxiety and agitation in the ICU. Which of the following medications should the nurse include in the conference? a. propofol