Nursing 275 Exam 4|339 Questions with Verified Answers,100% CORRECT, Exams of Nursing

Download Nursing 275 Exam 4|339 Questions with Verified Answers,100% CORRECT and more Exams Nursing in PDF only on Docsity! Nursing 275 Exam 4|339 Questions with Verified Answers CDE - CORRECT ANSWER The nurse meets with a patient who was a victim of sexual assault. Which statements made by the patient indicate recovery? Select all that apply. a. "I try not to think about the night that I was raped." b. "I realize that I am hopeless about trusting others." c. "I feel comfortable hanging out with my male friends." d. "I manage the really dark days by going to a gym class." e. "All of my bruises have healed, and I can wear tank tops again." bcd - CORRECT ANSWER A nurse caring for a patient who was sexually assaulted reports to the primary healthcare provider that the patient has effectively recovered. Which responses by the patient led the nurse to identify the patient's effective recovery? Select all that apply. a. The patient identifies emotions. b. The patient expresses the right to be protected. c. The patient starts interacting with family members. d. The patient expresses anger in a nondestructive way. e. The patient starts interacting verbally and nonverbally. a - CORRECT ANSWER A student nurse interacts with the sexual assault nurse examiner (SANE) during internship. The student nurse asks the SANE to share an experience while caring for victims of sexual assault. Which response given by the SANE is appropriate? a. "I have seen rape victims from 6 months to 90 years old." b. "I noticed that most rapes are impulsive acts of the rapists." c. "I feel that patients get severe injuries when they try to escape." d. "I overlook my feelings toward sexual assault before caring for the patient." b - CORRECT ANSWER Which nursing action has priority for a patient immediately following a reported rape? a. Provide written follow-up instructions. b. Document the debris and dirt on the patient's clothing. c. Give the patient alone time to recover after the incident. d. Give the patient prophylactic analgesics after the incident. abcde - CORRECT ANSWER Arrange the steps of the medical exam of a rape victim based on best practice guidelines. a. Head-to-toe physical assessment b. Genital examination c. Collection of evidence d. Documentation of biological and physical findings e. Treatment, discharge planning, and follow-up care a - CORRECT ANSWER When the nurse finishes addressing a group of college women about rape, the following comments are heard during the discussion period. Which comment calls for additional teaching by the nurse? a. "So if you dress conservatively, your risk of being raped is small." b. "Who would have guessed that most rape victims know the rapist?" c. "It makes sense that rape is a crime of violence, not a crime of sex." d. "I always thought rapes happened at night, but now I know that isn't true." b - CORRECT ANSWER The nurse is providing discharge teaching to a patient who was recently raped. What should the nurse say regarding the psychological effects of the assault? a. "You may feel hyperactive and notice an increased surge of energy." b. "It is normal to experience depression after being sexually assaulted." c. "People often report the need to be social after a sexual assault incident." d. "Let the healthcare provider know immediately if you feel scared or worried." ade - CORRECT ANSWER Which statement is true regarding the nursing care of a forensic patient? Select all that apply. a - CORRECT ANSWER A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic? a. Support the victim to separate issues of vulnerability from blame. b. Emphasize the importance of using a buddy system in public places. c. Reassure the victim that the outcome of the situation will be positive. d. Pose questions about the rape and help the patient explore why it happened. d - CORRECT ANSWER A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response. a. "Rape can happen anywhere." b. "Blaming yourself increases your anxiety and discomfort." c. "You are right. You should not have been alone on the street at night." d. "You feel as though this would not have happened if you had not been alone." d - CORRECT ANSWER The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient. a. The memory of the rape will be less vivid and less frightening. b. The patient is able to describe feelings of safety and relaxation. c. Symptoms of pain, discomfort, and anxiety are no longer present. d. The patient agrees to a follow-up appointment with a rape victim advocate. c - CORRECT ANSWER A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful and the victim is now in recovery? a. "I have a rash on my buttocks. It itches all the time." b. "Now I know what I did that triggered the attack on me." c. "I'm sleeping better although I still have an occasional nightmare." d. "I have lost 8 pounds since the attack, but I needed to lose some weight." b - CORRECT ANSWER A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim? a. "Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs." b. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." c. "Do you have any male friends who have also been victims of sexual assault?" d. "Why do you think you became a victim of sexual assault?" a - CORRECT ANSWER A nurse works at rape telephone hotline. Communication with potential victims should focus on a. explaining immediate steps victims should take. b. providing callers with a sympathetic listener. c. obtaining information for law enforcement. d. arranging counseling. d - CORRECT ANSWER A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for a. coma. b. seizures. c. hypotonia. d. respiratory depression. d - CORRECT ANSWER Before a victim of sexual assault is discharged from the emergency department, the nurse should a. notify the victim's family to provide emotional support. b. offer to stay with the patient until stability is regained. c. advise the patient to try not to think about the assault. d. provide referral information verbally and in writing. a - CORRECT ANSWER A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome? a. The acute phase reaction b. The long-term phase c. A delayed reaction d. The angry stage b - CORRECT ANSWER A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person's rights, the nurse should a. say, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information about physical and emotional reactions the person may experience. c. explain the need and importance of infectious disease and pregnancy tests. d. give verbal information about legal resources in the community. b - CORRECT ANSWER An unconscious teenager is treated in the emergency department. The teenager's friends suspect the teenager was drugged and raped at a party. Priority action by the nurse should focus on a. preserving rape evidence. b. maintaining physiological stability. c. determining what drugs were ingested. d. obtaining a description of the rape from a friend. a - CORRECT ANSWER A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response. a. "Are you thinking of harming yourself?" b. "It will take time, but you will feel the same as before the attack." A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient's safety, and interpersonal reassurance. A patient being seen in the clinic for superficial cuts on both wrists is pacing and sobbing. After a few minutes, the patient is calmer. The nurse attempts to determine the patient's perception of the precipitating event by asking: - CORRECT ANSWER "What was happening just before you started to feel this way?" A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits assessment of the precipitating event. "Why" questions are non-therapeutic. A patient comes to the crisis center saying, "I'm in a terrible situation. I don't know what to do." The triage nurse can initially assume that the patient is: - CORRECT ANSWER anxious and fearful. Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed with anxiety. An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? - CORRECT ANSWER Situational (Adventitious) Situation crisis arises from events that are extraordinary, external rather than internal and often unanticipated. An adventitious crisis is a crisis of disaster that is not a part of everyday life. It is unplanned or accidental. Adventitious crises include natural disasters, national disasters, and crimes of violence. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. Situational crisis arises from an external source such as a job loss, divorce, or other loss affecting self-concept or self-esteem. "Organic" is not a type of crisis. While conducting the initial interview with a patient in crisis, the nurse should: - CORRECT ANSWER speak in short, concise sentences. Severe anxiety narrows perceptions and concentration. By speaking in short concise sentences, the nurse enables the patient to grasp what is being said. Conveying urgency will increase the patient's anxiety. Letting the patient know who controls the interview or stating that time is limited is non-therapeutic. An adult seeks counseling after the spouse was murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response? - CORRECT ANSWER "Are you having thoughts of hurting yourself or others?" The highest nursing priority is safety. The nurse should assess suicidal and homicidal potential. The distracters are options, but the highest priority is safety. Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, "What else can happen?" What type of crisis is this person experiencing? - CORRECT ANSWER Situational A situational crisis arises from an external source and involves a loss of self- concept or self-esteem. An adventitious crisis is a crisis of disaster, such as a natural disaster or crime of violence. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists. A woman said, "I can't take anymore! Last year my husband had an affair, and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? - CORRECT ANSWER Clarify what the patient means by "I can't take anymore." During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help. Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully, "What else can happen?" If the woman's immediate family is unable to provide sufficient support, the nurse should: - CORRECT ANSWER ask what other relatives or friends are available for support. The assessment of situational supports should continue. Even though the patient's nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually non- therapeutic. Strategies of crisis intervention address the immediate cause of the crisis and restoration of emotional security and equilibrium. The goal is to return the individual to the pre-crisis level of function. Crisis intervention is, by definition, short term. The correct response is the most global answer. Promoting growth is a focus of long-term therapy. Providing legal assistance might or might not be applicable. After celebrating the fortieth birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? - CORRECT ANSWER Maturational Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual, such as divorce and job loss. There is no classification called reactive. Adventitious crises occur when disasters, such as natural disasters (e.g., floods, hurricanes), war, or violent crimes, disrupt coping. Which scenario is an example of an adventitious crisis? - CORRECT ANSWER A riot at a rock concert The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of situational or maturational crises. Which agency provides coordination in the event of a terrorist attack? - CORRECT ANSWER National Incident Management System (NIMS) The National Incident Management System (NIMS) provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations. During the initial interview at the crisis center, a patient says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." Which comment should the nurse use to assess personal coping skills? - CORRECT ANSWER "In the past, how have you handled difficult or stressful situations?" The correct answer is the only option that assesses coping skills. The incorrect options are concerned with self-esteem, ask the patient to decide on treatment at a time when he or she "cannot think clearly," and seek to explore issues tangential to the crisis. An adult has cared for a debilitated parent for 10 years. The parent's condition recently declined, and the health care provider recommended placement in a skilled nursing facility. The adult says, "I've always been able to care for my parents. Nursing home placement goes against everything I believe." Successful resolution of this person's crisis will most closely relate to: - CORRECT ANSWER resolving the feelings associated with the threat to the person's self-concept. The patient's crisis clearly relates to a loss of (or threatened change in) self- concept. Her capacity to care for her parents, regardless of the deteriorating condition, has been challenged. Crisis resolution will involve coming to terms with the feelings associated with this loss. Identifying situational supports is relevant, but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but not the primary factor associated with resolution in this case. Automatic relief behaviors will not be helpful. Automatic relief behaviors are part of the fourth phase of crisis. The principle most useful to a nurse planning crisis intervention for any patient is that the patient: - CORRECT ANSWER is experiencing a state of disequilibrium. Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. Potential for self-violence or other-directed violence may or may not be a factor in crisis. A nurse assesses a patient in crisis. Select the most appropriate question for the nurse to ask to assess this patient's situational support. - CORRECT ANSWER "Who can be helpful to you during this time?" Only the answer focuses on situational support. The incorrect options focus on the patient's perception of the precipitating event. An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies? - CORRECT ANSWER Powerlessness This community has experienced a catastrophic event. There are five phases of the disaster management continuum. The nurses' activities applied to mitigation (attempts to limit a disaster's impact on human health and community function) and response (actual implementation of a disaster plan). Preparedness occurs before an event. Recovery actions focus on stabilizing the community and returning it to its previous status. Evaluation of the response efforts apply to the future. b - CORRECT ANSWER A patient who has been diagnosed with dissociative identity disorder asks, "What exactly are 'alters'? My health care provider told me I have several of them." Which statement by the patient illustrates that the education provided has been effective? a. "Alters are never aware of each other." b. "Alters are separate personalities that take over during stress." c. "Alters are based in mysticism and religiosity, such as demons." d. "Alters are just like me, but they have no memory of the trauma I went through." d - CORRECT ANSWER A child reared in a minority culture is at greatest risk for: a. Bullying b. Homicidal thoughts c. Eating- and sleep-related disorders d. Traumatic experiences in early childhood b - CORRECT ANSWER What information should the nurse give to the family of a patient who has had a dissociative episode? a. Brief periods of psychotic behavior may occur b. Dissociation is a method for coping with severe stress c. Dissociation suggests the possibility of early dementia d. Ways to intervene to prevent self-mutilation and suicide attempts bdef - CORRECT ANSWER The nurse is assessing a young child for posttraumatic stress disorder (PTSD). What does the nurse include in the assessment? Select all that apply. a. Bowel habits b. Motor function c. Blood pressure d. Speech patterns e. General appearance f. Characteristics of play c - CORRECT ANSWER When caring for a child with posttraumatic stress disorder, which intervention should the nurse include in the patient plan of care? a. Provide changeable environment. b. Help patient learn positive avoidance. c. Reduce stimulation of traumatic memories. d. Promote arousal to build tolerance to stress. a - CORRECT ANSWER Which assessment tool does the nurse use while assessing a patient with dissociative identity disorder? a. Somatoform questionnaire b. Child dissociative checklist c. Child sexual behavior inventory d. Posttraumatic stress disorder screening a - CORRECT ANSWER A patient who is a victim of sexual assault has insomnia, reduced concentration, anxiety, and recurring thoughts of the event. Which medication does the nurse anticipate being prescribed for the patient? a. Clonidine b. Citalopram c. Propranolol d. Desipramine b - CORRECT ANSWER A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the patient learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support "numbing" as a temporary way to manage intolerable feelings. d - CORRECT ANSWER Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who a. visit their teenager's grave daily. b. return immediately to employment. c. discuss the accident within the family only. d. create a scholarship fund at their child's high school b - CORRECT ANSWER After the sudden death of his wife, a man says, "I can't live without her ... she was my whole life." Select the nurse's most therapeutic reply. a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "It's important to recognize that she is no longer suffering." d. "Your friends will help you cope with this change in your life." c - CORRECT ANSWER A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." How should the nurse analyze this behavior? a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The patient had ambivalent feelings about her husband. b - CORRECT ANSWER A patient diagnosed with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." Which intervention would be most appropriate at this point? a. Notify the health care provider of this change in the patient's behavior. b. Engage the patient in a physical activity such as exercise. c. Isolate the patient until the sensation has diminished. d. Administer a prn dose of antianxiety medication. c - CORRECT ANSWER A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system b - CORRECT ANSWER The gas pedal on a person's car became stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this experience, afterward, which assessment finding would the nurse expect? a. Weight gain b. Flashbacks c. Headache d. Diuresis c - CORRECT ANSWER A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with PTSD. The nurse's highest priority is to screen this soldier for a. bipolar disorder. b. schizophrenia. c. depression. d. dementia. b - CORRECT ANSWER Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my home, family, and friends." b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education, but I'm not sure how I will fit in with other college students." b - CORRECT ANSWER A soldier returned home from active duty in a combat zone and was diagnosed with PTSD. The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination d - CORRECT ANSWER A soldier returned 3 months ago from a combat zone and was diagnosed with PTSD. Which social event would be most disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th b - CORRECT ANSWER Which comment by the parents of young children best demonstrates support of development of resilience and effective stress management? a. "Our children will be stronger if they make their own decisions." b. "We spend daily family time talking about experiences and feelings." c. "We use three different babysitters. All of them have college degrees." d. "Our parenting strategies are different from those our own parents used." a - CORRECT ANSWER A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with PTSD is the soldier describing? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis c - CORRECT ANSWER A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with PTSD? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis d - CORRECT ANSWER A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family, but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a. "Posttraumatic stress disorder (PTSD) often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support." cde - CORRECT ANSWER Which experiences are most likely to precipitate PTSD? (Select all that apply). a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks b - CORRECT ANSWER A nurse prepares the plan of care for a school-age child diagnosed with reactive attachment disorder. Which initial outcome should be the focus of the nurse's intervention? The child will: a. Decrease impulsive behavior b. Express feelings through journaling c. Verbally recount traumatic experiences d. Correctly identify the date, time, and place abd - CORRECT ANSWER The nurse is planning care for a patient diagnosed with a dissociative disorder. Which intervention is directed primarily towards minimizing the patient's anxiety level? Select all that apply. a. Provide a simple, predictable daily routine. b. Teach and reinforce relaxation and deep breathing techniques. c. Work with the patient and involved parties to reestablish relationships. d. Allow the patient to progress at his or her own pace as memories are recovered. e. Provide support through empathetic listening during disclosure of painful experiences. c - CORRECT ANSWER A nurse is developing a plan of care for a patient with dissociative amnesia. Which strategies should the nurse include in the plan? a. Allow the patient to rest. b. Ask the patient to recollect past events. c. Instruct the patient on grounding techniques. d. Ask the family member to make routine decisions. a - CORRECT ANSWER A nurse conducts an initial interview with a veteran of two tours in the war with Iraq. The veteran says, "The war was years ago, but I still remember my friends who were killed. I don't know why I lived and they died." What is the nurse's priority response? a. "Are you having any thoughts of harming yourself?" b. "It's important to think about how good your life is now." c. "Are you saying you have some guilt about being a survivor?" d. "The outcomes of war are tragic and stay with us for many years." ace - CORRECT ANSWER A nurse is assessing a child who has witnessed violence at home. What should the nurse document when completing an admission genogram of the child? Select all that apply. a. Relationships b. Investigations c. Family history d. Laboratory testing e. Family composition b - CORRECT ANSWER A nurse is performing an assessment of a child diagnosed with disinhibited social engagement disorder. Which behavior should the nurse expect to find in the child? a. The child throws stones at strangers. b. The child willingly goes with a stranger. c. The child cries when touched by a stranger. d. The child hides when a stranger approaches abdc - CORRECT ANSWER A nurse is caring for a child who needs treatment for mental trauma. Place the stages of the staged treatment protocol in the correct order. a. Provide safety. b. Reduce arousal. c. Nurture self-awareness. d. Teach coping skills. b - CORRECT ANSWER The nurse is caring for a patient with dissociative amnesia disorder. The patient gets extremely aggressive due to anxiety and causes physical harm to him or herself and to others. Which nursing intervention does the nurse follow to reduce anxiety and aggression in the patient? a. The nurse lets the patient make decisions on major issues. b. The nurse frequently observes the patient by visiting the patient's room. c. The nurse reminds the patient about the happy moments of the patient's life. d. The nurse prepares a schedule and instructs the patient to follow it regularly. d - CORRECT ANSWER Empathetic listening is therapeutic because it focuses on: a. Reducing anxiety b. Encouraging resilience c. Enhancing self-esteem d. Lessening feelings of isolation abce - CORRECT ANSWER What symptoms are included in adjustment disorder? Select all that apply. a. Guilt b. Anger c. Depression d. Overachieving e. Social withdrawal c - CORRECT ANSWER According to attachment theory, relationship disorders are related to trauma associated with: a. Culture or religion b. Siblings or strangers c. Caregivers or parents d. Insufficient food or shelter bcde - CORRECT ANSWER Which child should be assessed for possible posttraumatic stress disorder (PTSD) as a result of exposure to major trauma in his or her life? Select all that apply. a. A 3-year-old whose older sibling was born with both physical and cognitive impairments. b. A 4-year-old who was hospitalized for two months after being injured in an automobile accident. c. An 8-year-old child who has a medical history that includes several broken bones and a dislocated shoulder. d. A 5-year-old child who lives with grandparents since his or her single parent was deployed by the military 10 months ago. e. A 12-year-old who has been in cancer remission for three years since finishing both chemotherapy and radiation treatments. a - CORRECT ANSWER A patient who is a victim of sexual assault has insomnia, reduced concentration, anxiety, and recurring thoughts of the event. Which medication does the nurse anticipate being prescribed for the patient? a. Clonidine b. Citalopram c. Propranolol d. Desipramine Cyclobenzaprine (Amrix, Flexeril) is prescribed for a patient with muscle spasms of the lower back. Appropriate nursing interventions would include which of the following? (Select all that apply.) A. Assessing the heart rate for tachycardia B.Assessing the home environment for patient safety concerns C.Encouraging frequent ambulation D. Providing oral suction for excessive oral secretions E. Providing assistance with activities of daily living such as reading - CORRECT ANSWER A. Assessing the heart rate for tachycardia B.Assessing the home environment for patient safety concerns E. Providing assistance with activities of daily living such as reading Adverse reactions to cyclobenzaprine include drowsiness, dizziness, dry mouth, rash, blurred vision, and tachycardia. Because the medication can cause drowsiness and dizziness, ensuring patient safety must be a priority. The patient may need assistance with reading or other activities requiring visual acuity if blurred vision occurs. Options 3 and 4 are incorrect. Patients who are experiencing back pain often have orders for limited ambulation until muscle spasms have subsided. The patient is scheduled to receive rimabotulinumtoxinB (Myobloc) for treatment of muscle spasticity. Which of the following will the nurse teach the patient to report immediately? A.Fever, aches, or chills B. Difficulty swallowing, ptosis, blurred vision C. Continuous spasms and pain on the affected side D. Moderate levels of muscle weakness on the affected side - CORRECT ANSWER B. Difficulty swallowing, ptosis, blurred vision Dysphagia, ptosis, and blurred vision are all symptoms of possible botulinum toxin B toxicity and must be reported immediately. Options 1, 3, and 4 are incorrect. Fever, aches, and chills are not anticipated side effects. Moderate levels of muscle weakness may occur after the drug is administered, and strengthening exercises may be needed on the affected side. Continuous muscle spasms and pain should not occur because the drug blocks muscle contraction. A patient has purchased capsaicin over-the-counter cream to use for muscle aches and pains. What education is most important to give this patient? A. Apply with a gloved hand only to the site of pain. B. Apply the medication liberally above and below the site of pain. C. Apply to areas of redness and irritation only. D. Apply liberally with a bare hand to the affected limb. - CORRECT ANSWER A. Apply with a gloved hand only to the site of pain. Capsaicin should be applied to the site of pain with a gloved hand to avoid introducing the capsaicin to the eyes or other parts of the body not under treatment. Options 2, 3, and 4 are incorrect. Capsaicin should be applied only to the site of pain and never with the bare hand. It should not be applied to irritated or open skin areas and should be discontinued if irritation occurs. A patient has been prescribed clonazepam (Klonopin) for muscle spasms and stiffness secondary to an automobile accident. While the patient is taking this drug, what is the nurse's primary concern? A. Monitoring hepatic laboratory work B. Encouraging fluid intake to prevent dehydration C. Assessing for drowsiness and implementing safety measures D. Providing social services referral for patient concerns about the cost of the drug - CORRECT ANSWER C. Assessing for drowsiness and implementing safety measures Clonazepam (Klonopin) is a benzodiazepine; because it works on the C N S, it may cause significant drowsiness and dizziness. Safety measures should be implemented to prevent falls and injury. Options 1, 2, and 4 are incorrect. Benzodiazepines may cause hepatotoxicity in patients with existing hepatic insufficiency and may be needed for long-term monitoring. This drug was prescribed after a health care provider's assessment and is currently given to treat a potential short-term condition. The drug should not cause dehydration and is available in generic form. If cost is a concern, social service aid may be needed, but the primary concern for the nurse is safety. A female patient is prescribed dantrolene (Dantrium) for painful muscle spasms associated with multiple sclerosis. The nurse is writing the discharge plan for the patient and will include which of the following teaching points? (Select all that apply.) A. If muscle spasms are severe, supplement the medication with hot baths or showers three times per day. B. Inform the health care provider if she is taking estrogen products. C. Sip water, ice, or hard candy to relieve dry mouth. D. Return periodically for required laboratory work. E. Obtain at least 20 minutes of sun exposure per day to boost vitamin D levels. - CORRECT ANSWER B. Inform the health care provider if she is taking estrogen products. pressure every 2 hours. Diarrhea should be reported but is unrelated to the effects of levodopa, and other causes should be explored. An increase in tremors should be evaluated, and the dose of the drug should not be independently increased. The nurse discusses the disease process of multiple sclerosis with the patient and caregiver. The patient will begin taking glatiramer (Copaxone), and then nurse is teaching the patient about the drug. Which of the following points should be include? 1. Drink extra fluids while this drug is given. 2. Local injection site irritation is a common effect. 3. Take the drug with plenty of water and remain in an upright position for at least 30 minutes. 4. The drug causes a loss of vitamin C so include extra citrus and foods containing vitamin C in the diet. - CORRECT ANSWER Answer: 2 Rationale: Glatiramer (Copaxone) is given by injection and often causes injection site irritation. Options 1, 3, and 4 are incorrect. Extra fluids do not need to be included and the drug is not given orally. It does not deplete vitamin C from the body. The nurse knows that which of the following are major disadvantages for the use of donepezil (Aricept) to treat the symptoms of early Alzheimer's disease? (Select all that apply.) 1. It must be administered four times per day. 2. It may cause significant weight loss. 3. It may cause potentially fatal cardiac dysrhythmias. 4. It may cause serious hepatic damage. 5. It results in only modest cognitive improvement and results do not last. - CORRECT ANSWER Answer: 2, 3, 4, 5 Rationale: Donepezil (Aricept) may cause serious liver damage and potentially fatal dysrhythmias including severe bradycardia and heart block. It may also cause significant weight loss, and the patient's weight should be monitored. While cognitive improvement may be observed in as few as 1 to 4 weeks, patients should receive pharmacotherapy for at least 6 months prior to assessing maximum benefits of drug therapy. Unfortunately, cognitive improvement is only modest and short-term. Option 1 is incorrect. Donepezil is taken once per day usually at bedtime. An early sign(s) of levodopa toxicity is (are) which of the following? 1. orthostatic hypotension 2. drooling 3. spasmodic eye winking and muscle twitching 4. nausea, vomiting, and diarrhea - CORRECT ANSWER Answer: 3 Rationale: Blepharospasm (spasmodic eye winking) and muscle twitching are early signs of potential overdose or toxicity. Options 1, 2, and 4 are incorrect. Orthostatic hypotension is a common adverse effect of both PD and many drugs used to treat the condition but is not a symptom of overdosage or toxicity. Drooling, nausea, vomiting, and diarrhea are also not symptoms of overdose or toxicity. A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client's activity tolerance? a. Vital signs before, during, and after activity b. Body image and self-care abilities c. Ability to use assistive or adaptive devices d. Client's electrocardiography readings - CORRECT ANSWER A A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this client's teaching prior to beginning rehabilitation activities? a. "Use analgesics before and after activity, even if you are not experiencing pain." b. "Let me know if you start to experience shortness of breath, chest pain, or fatigue." c. "Do not take your prescribed beta blocker until after you exercise with physical therapy." d. "If you experience knee pain, ask the physical therapist to reschedule your therapy." - CORRECT ANSWER B A rehabilitation nurse prepares to move a client who has new bilateral leg amputations. Which is the best approach? a. Use the bear-hug method to transfer the client safely. b. Ask several members of the health care team to carry the client. c. Utilize the facility's mechanical lift to move the client. d. Consult physical therapy before performing all transfers. - CORRECT ANSWER C A nurse performs passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. Which action should the nurse take next? a. Splint the joint and continue passive range of motion to the shoulder only. b. Progressively increase joint motion 5 degrees beyond resistance each day. c. Apply weights to the right distal extremity before initiating any joint exercise. d. Continue to move the joint only to the point at which resistance is met. - CORRECT ANSWER D A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this client's risk of fracture? a. Apply shoes to improve foot support. b. Perform weight-bearing activities. c. Increase calcium-rich foods in the diet. d. Use pressure-relieving devices. - CORRECT ANSWER B A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement? a. Passive range of motion b. Active range of motion c. Resistive range of motion d. Aerobic exercise - CORRECT ANSWER B A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation? a. Nutritional intake and serum albumin levels b. Pressure ulcer diameter and depth c. Wound drainage, including color, odor, and consistency d. Dressing site and antibiotic ointment application - CORRECT ANSWER A An interdisciplinary team is caring for a client on a rehabilitation unit. Which team members are paired with the correct roles and responsibilities? (Select all that apply.) a. Speech-language pathologist - Evaluates and retrains clients with swallowing problems b. Physical therapist - Assists clients with ambulation and walker training c. Recreational therapist - Assists physical therapists to complete rehabilitation therapy d. Vocational counselor - Works with clients who have experienced head injuries e. Registered dietitian - Develops client-specific diets to ensure client needs are met - CORRECT ANSWER A B E A rehabilitation nurse is caring for an older adult client who states, "I tire easily." How should the nurse respond? (Select all that apply.) a. "Schedule all of your tasks for the morning when you have the most energy." b. "Use a cart to push your belongings instead of carrying them." c. "Your family should hire someone who can assist you with daily chores." d. "Plan to gather all of the supplies needed for a chore prior to starting the activity." e. "Try to break large activities into smaller parts to allow rest periods between activities." - CORRECT ANSWER B D E A nurse is caring for clients as a member of the rehabilitation team. Which activities should the nurse complete as part of the nurse's role? (Select all that apply.) a. Maintain the safety of adaptive devices by monitoring their function and making repairs. b. Coordinate rehabilitation team activities to ensure implementation of the plan of care. c. Assist clients to identify support services and resources for the coordination of services. d. Counsel clients and family members on strategies to cope with disability. e. Support the client's choices by acting as an advocate for the client and family. - CORRECT ANSWER B E The nurse is taking a history on an adult pt who reports acute back pain. Which question is the nurse most likely to ask to identify causative factors? a. "Have you had a recent fall or accident or lifted a heavy object?" b. "Do you have a family history for neurologic disorders?" c. "Are you having trouble walking or maintaining your balance?" d. "Are you having pain that radiates down the back of your leg?" - CORRECT ANSWER a. "Have you had a recent fall or accident or lifted a heavy object?" The nurse is preparing to physically assess a pt's report of parasthesia in the lower extremities. To accomplish this assessment, which assessment technique does the nurse use? a. Use a doppler to locate the pedal pulse, the dorsalis pedis pulse, or the popliteal pulse. b. Ask the patient to identify sharp and dull sensation by using a paper clip and a cotton ball. c. Use a reflex hammer to test for deep tendon patellar or Achilles reflexes. d. Ask the patient to walk across the room and observe gait and equilibrium. - CORRECT ANSWER b. Ask the patient to identify sharp and dull sensation by using a paper clip and a cotton ball. Which position is therapeutic and comfortable for a patient with acute lower back pain from a herniated disc? a.Semi-Fowler's position with a pillow under the knees to keep them flexed. b. Supine position with arms and legs in a correct anatomical position. c. Orthopneic position; sitting with trunk slightly forward; arms supported with a pillow d. Modified Sim's position with upper arm and leg supported by pillows. - CORRECT ANSWER a.Semi-Fowler's position with a pillow under the knees to keep them flexed. A pt has been talking to the provider about drugs that could potentially be used in the treatment of low back pain. Which statement by the pt indicates a need for additional teaching? a. "The doctor may prescribe a muscle relaxant, so I should not drive or operate machinery until I see how it will affect me." b. "The doctor may suggest OTC ibuprofen; therefore I should watch for and report dark or tarry stools." c. "The doctor may prescribe an oral steroid such as prednisone; this would be short-term therapy, and the dose would gradually taper off." d. "The doctor may prescribe an opioid medication, and it may cause drowsiness; I should not drive or drink alcohol when I take it." - CORRECT ANSWER d. "The doctor may prescribe an opioid medication, and it may cause drowsiness; I should not drive or drink alcohol when I take it." A pt is scheduled for lumbar surgery. Which key points must the nurse include in a pre-operative teaching plan for this patient? Select all that apply. a. Techniques for getting in and out of bed b. Expectations for turning and moving in bed c. Limitations and restrictions for home activities. d. Restricted to bed rest for at least 48 hrs e. Immediately report any numbness and tingling f. Expect difficulties moving affected leg or both legs - CORRECT ANSWER a. Techniques for getting in and out of bed b. Expectations for turning and moving in bed c. Limitations and restrictions for home activities. e. Immediately report any numbness and tingling f. Expect difficulties moving affected leg or both legs The nurse is assessing a patient who presented to the emergency department reporting acute onset numbness and tingling in the right leg. How does the nurse document this subjective finding? a. Paraparesis b. Parasthesia c. Ataxia d. Quadriparesis - CORRECT ANSWER b. Parasthesia A pt has just undergone spinal fusion and a laminectomy and has returned from the operating room. Which assessments are done in the first 24 hrs? Select all that apply. a. What were the location and position of the patient immediately after injury? b. Were there problems extricating the patient from the water? c. Have the parents been notified to get permission for treatment? d. What symptoms were reported by bystanders and noted en route? e. What changes occurred at the scene or en route? f. What treatments were given at the scene or en route? - CORRECT ANSWER a. What were the location and position of the patient immediately after injury? b. Were there problems extricating the patient from the water? d. What symptoms were reported by bystanders and noted en route? e. What changes occurred at the scene or en route? f. What treatments were given at the scene or en route? The nurse is caring for a patient with a spinal cord injury who is experiencing neurogenic shock. The pt has a dopamine drip, but the systolic blood pressure is 88 mmHg. there is a new order to infuse 500 mL of dextran-40 over 4 hrs. At what rate does the nurse set the infusion pump? a. 75 mL/hr b. 100 mL/hr c. 125 mL/hr d. 150 mL/hr - CORRECT ANSWER c. 125 mL/hr A patient who was involved in a high speed motor vehicle accident sustained multiple injuries. He is transported to the emergency department by EMS with immobilization devices in place. There is a high probability of cervical spine fracture; the pt has altered mental status and extremities are flaccid. What is the priority assessment for this patient? a. Check the mental status using the Glasgow Coma Scale b. Assess the respiratory pattern and ensure a patent airway c. Observe for intra-abdominal bleeding and hemorrhage. d. Assess for loss of motor function and sensation. - CORRECT ANSWER b. Assess the respiratory pattern and ensure a patent airway The nurse is caring for a patient who is experiencing spinal shock. What are the expected findings that occur with the condition? a. Temporary loss of motor, sensory, reflex and autonomic functions. b. Stridor, garbled speech, or inability to clear airway c. Hypotension and a decreased LOC d. Bradycardia and decreased UO - CORRECT ANSWER a. Temporary loss of motor, sensory, reflex and autonomic functions. Which neuro assessment technique does the nurse use to test a patient for sensory function? a. Touch the skin with a clean paper clip and ask whether it feels sharp or dull. b. Ask the patient to elevate both arms off the bed and extend wrists and fingers. c. Have the patient close the eyes and move toes up or down, while identifying the positions. d. Have the patient sit with legs dangling; use a reflex hammer to test reflex responses - CORRECT ANSWER a. Touch the skin with a clean paper clip and ask whether it feels sharp or dull. Assessment of a patient with a lower spinal cord injury confirms that the patient has paralysis of the bilateral lower extremities. How does the nurse document this finding? a. Paraparesis b. Paraplegia c. Quadriparesis d. Quadriplegia - CORRECT ANSWER b. Paraplegia Which symptoms indicate that a pt with a spinal cord injury is experiencing autonomic dysreflexia? Select all that apply. a. Flaccid paralysis b. Hypertension c. Tachypnea d. Severe headache e. Blurred vision f. Loss of reflexes below the injury - CORRECT ANSWER b. Hypertension d. Severe headache e. Blurred vision The nurse is assessing a pt with a spinal cord injury that occurred several months ago. The nurse recognizes that the patient is experiencing autonomic dysreflexia. What is the nurse's first priority action? a. Check for bladder distention b. Raise the head of bed c. Administer an anti-hypertensive med d. Notify the provider - CORRECT ANSWER b. Raise the head of bed Which patient behavior is most likely to occur with spinal shock? a. Demonstrates restlessness and is easily agitated b. Displays inability or difficulty moving extremities c. Is disoriented to person, place, and time d. Reports severe pain that radiates down the spine - CORRECT ANSWER b. Displays inability or difficulty moving extremities The nurse is preparing a patient with quadriplegia for discharge and has taught the spouse to assist the patient with a "quad cough" to prevent respiratory complications. Which observation indicates that the spouse has understood what has been taught? a. Spouse assists the patient into a wheelchair or chair and coaches him to do deep coughing. b. Spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales. c. Spouse places her hands on the pt's lateral chest and pushes inward as the patient exhales. d. Spouse assists the pt into high Fowler's position and encourages him to take deep breaths. - CORRECT ANSWER b. Spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales. The nurse is caring for a pt with recent SCI. Which interventions does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? Select all that apply. a. Methylprednisolone b. Dextran c. Atropine d. Dopamine - CORRECT ANSWER c. Atropine The nurse is planning care for a 66 year old pt with SCI. Based on the nurse's knowledge of the most likely complication and cause of death for this patient, what would the nurse recommend? a. Increase calcium intake and exercise against resistance b. Ensure influenza and pneumococcus vaccinations are current c. Drink adequate liquids and eat a high-fiber diet d. Practice meticulous skin care; including frequent repositioning - CORRECT ANSWER b. Ensure influenza and pneumococcus vaccinations are current An adolescent pt has quadriplegia as a result of a diving accident. The UAP reports that the pt starting yelling and spitting at her while she was trying to bathe him. He is angry and hostile, stating "Nobody is going to do anything else to me! I'm going to get out of this place!" What is the priority patient problem? a. Noncompliance with treatment plan b. Self-care deficit for hygeine c. Difficulties with situational coping d. Feelings of hopelessness - CORRECT ANSWER c. Difficulties with situational coping The nurse is giving home care instructions to a patient who will be discharged with a halo device. What does the nurse instruct the patient to avoid? a. Going out in the cold b. Driving c. Sexual activity d. Bathing in the bathtub - CORRECT ANSWER b. Driving Which disorder could have similar clinical presentation to multiple sclerosis? a. Amyotrophic lateral sclerosis b. Spinal cord tumor c. Guillan-Barre d. Quadriplegia - CORRECT ANSWER a. Amyotrophic lateral sclerosis A patient reports increased fatigue and stiffness of the extremities. These symptoms have occurred in the past, but they resolved and no medication attention was sought. Which question does the nurse ask to assess whether the symptoms may be associated with MS? Select all that apply. a. "Are you having persistent headaches that occur with stress?" b. "Do you have a persistent sensitivity to temperature?" c. "Do you ever have slurred speech or trouble swallowing?" d. "Are you having trouble breathing with minimal exertion?" e. "Has anyone in your family been diagnosed with multiple sclerosis?" f. "Do you have spasms at night that wake you from your sleep?" - CORRECT ANSWER b. "Do you have a persistent sensitivity to temperature?" c. "Do you ever have slurred speech or trouble swallowing?" e. "Has anyone in your family been diagnosed with multiple sclerosis?" f. "Do you have spasms at night that wake you from your sleep?" A patient tells the nurse, "I have symptoms of multiple sclerosis, and I have been dealing with them for so long! Why won't anyone help me?" Which intervention should the nurse employ first? a. Help the patient to locate and make an appointment with a specialist b. Ask the patient to describe the symptoms and past treatments c. Encourage the patient to verbalize feelings and frustrations d. Give the patient a brochure about the diagnosis and treatment of MS. - CORRECT ANSWER c. Encourage the patient to verbalize feelings and frustrations The home health nurse sees in the patient's record that he takes riluzole. Which question is the nurse most likely to ask? a. When were you first diagnosed with amyotrophic lateral sclerosis? b. Has the medication relieved any of the symptoms caused by multiple sclerosis? c. Has your acute back pain returned to the more familiar chronic pain? d. Have you always had neurogenic bladder problems since your spinal cord injury? - CORRECT ANSWER a. When were you first diagnosed with amyotrophic lateral sclerosis? A pt with MS is prescribed oral fingolimod. Which key point must the nurse teach the patient about this drug? a. "You must be carefully monitored for allergic reactions bc the drug tends to build up in the body." b. "We need to teach you how to monitor your pulse rate bc this drug can cause a slow heart rate." c. "This drug will decrease the frequency of clinical relapses, but there is an increased risk for stroke." d. "The medication will improve your ability to walk, but it also increases the risk for seizures." - CORRECT ANSWER b. "We need to teach you how to monitor your pulse rate bc this drug can cause a slow heart rate." The nurse has provided teaching to the husband of a 33 year old woman who was recently diagnosed with MS. Which statement by the pt's husband indicates he needs additional teaching on the course of the illness? a. "She could fall bc she may lose her balance and have poor coordination." b. "Eventually she will not be able to drive because of vision problems." c. "She will probably have a decreased libido and diminished orgasm." d. "As the disease progresses, she could have intermittent short-term memory loss." - CORRECT ANSWER d. "As the disease progresses, she could have intermittent short-term memory loss." The nurse is teaching a pt with multiple sclerosis and her family about her exercise program. Which points must the nurse include? Select all that apply. a. ROM exercises are an important component b. Stretching should precede rigorous activity c. Increased body temperature can lead to increased fatigue d. Steadily increasing walking distances can lead to jogging e. Stretching and strengthening exercises will be part of your program the room. A private room is preferred for this client. If a private room is not available, the client may be cohorted with another client with the same active infection and with the same microorganisms if no other infection is present. The client does not require respiratory isolation and does not need to wear a surgical mask when being transported out of the room because the infection is not airborne. Use of a mask is not the best way to prevent the spread of this infection. Which statement about the transmission of hepatitis C is correct? A. Feces are a likely body fluid by which to transmit the disease. B. Airborne Precautions are used for the prevention of hepatitis C. C. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. D. No precautions are necessary with the use of nail clippers or scissors. - CORRECT ANSWER C. Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. Hepatitis C is a bloodborne pathogen. Equipment or linen that is soiled with blood or body fluids can be a likely source of infection. Washing with bleach or a disinfectant will help prevent the spread of infection. Feces are not a likely source of transmission of hepatitis C. The hepatitis C virus is not airborne, so Airborne Precautions are not necessary. Hepatitis C can be spread by contact with contaminated items, such as clippers or scissors, so these items should be disinfected regularly. A client who was treated last month for a bad case of bronchitis and walking pneumonia reports many of the same symptoms today. Which factor in the client's antibiotic therapy most likely caused the client's relapse? A. Taking the antibiotic before jogging 2 miles daily. B. Taking the antibiotic most days. C. Taking the antibiotic as prescribed. D. Taking the antibiotic with a full glass of water. - CORRECT ANSWER B. Taking the antibiotic most days. Antibiotics not taken as prescribed can result in recurring symptoms, as well as the development of drug-resistant infections and other emerging infections. Taking the antibiotic before jogging is not a contributing factor to the client's relapse. The client who is taking antibiotics as prescribed is not likely to develop recurring symptoms. Taking antibiotics with a full glass of water is a positive action and neither hinders nor promotes antimicrobial therapy. Which nurse does the charge nurse assign to care for a 64-year-old client who has pneumonia and requires IV antibiotic therapy and IV fluids at 200 mL/hr? A. An experienced LPN/LVN who has worked on the medical unit for 10 years. B. An RN with experience in the operating room who transferred a month ago to the medical unit. C. A float RN with 7 years of experience on the inpatient oncology unit. D. An RN who has worked mostly on the same-day surgery unit since graduating a year ago. - CORRECT ANSWER C. A float RN with 7 years of experience on the inpatient oncology unit. The float RN with experience on the inpatient oncology unit would be familiar with complications and assessment for IV fluids and pneumonia. LPN/LVNs do not have the scope of practice to provide care to this client. The RN with experience in the operating room or the RN who has worked mostly on the same-day surgery unit does not have the experience needed to care for an unstable client on an unfamiliar unit. Which is a common clinical manifestation of infectious disease? A. Dry and pink skin B. Hypothermia C. Decreased respiratory rate D. Fever - CORRECT ANSWER D. Fever Fever (generally a temperature above 101°F [38.3°C]) is a common clinical manifestation of infection. Skin tends to be warm and moist, not dry and pink, when an infectious disease is present. Clients typically have hyperthermia (fever), not hypothermia, when an infectious disease is present, although some clients can have infection without fever. Respiratory rate typically increases, as does the heart rate, with infectious disease. Which client is at greatest risk for developing an infection? A. A 54-year-old man with hypertension B. A 17-year-old girl with a fractured tibia in a cast C. A 65-year-old woman who had coronary bypass surgery 4 days ago D. A 71-year-old man in a nursing home - CORRECT ANSWER C. A 65-year-old woman who had coronary bypass surgery 4 days ago Older clients such as the 65-year-old people with decreased vascularity to the integumentary system (from the bypass surgery) and compromised skin (surgical incision) are at risk for infection. No coexisting conditions are present for the client with hypertension to be at risk for infection. The 71-year-old client in a nursing home is not at highest risk because no coexisting conditions make this client most vulnerable to infection. Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? A. Carefully wash hands that are visibly soiled. B. Wear a mask and gloves when the client's body secretions or body fluids are likely to be handled. C. Wear a mask with eye protection and perform proper handwashing. D. Wear gloves when contact with body secretions or body fluids is expected. - CORRECT ANSWER D. Wear gloves when contact with body secretions or body fluids is expected. The nurse must wear gloves and wash hands before and after potential exposure to the client's body secretions or fluids. C. difficile infection requires contact precautions. Hands must be properly washed before and after any contact with the client with C. difficile infection. Alcohol-based hand rubs are not effective for hand hygiene in the care of clients with C. difficile. Hands must be washed even if not visibly soiled. It is not necessary to wear a mask when caring for clients with C. difficile infection. A mask and eye protection are not necessary to prevent transmission of C. difficile. D. Most antibiotics are effective for infection. - CORRECT ANSWER A. Antibiotics have been given to clients for conditions that do not require antibiotics. Antibiotics have often been prescribed for conditions that do not require them, or have been given at higher doses or for longer periods of time than needed. As a result, a number of microorganisms have become resistant to certain antibiotics. Microorganisms are more resistant to certain antibiotics. Strictly adhered-to Standard Precautions are adequate to prevent infection. Most antibiotics are not effective for every infection. Which statement about handwashing is in accordance with recommendations by the Centers for Disease Control and Prevention? A. If gloves are worn between treatments for clients sharing a room, handwashing is not necessary until the nurse has finished assessing the second client. B. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. C. Handwashing does not need to be done after resetting a client's IV pump. D. If the hands are not visibly soiled, washing the hands is not necessary. - CORRECT ANSWER B. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. Microorganisms that can be transmitted to another client can be found on intact skin. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, any equipment connected to the client, and contaminated items; immediately after removing gloves; and between client contacts. Which intervention is the most appropriate to address the priority problem of feelings of isolation when caring for a client who is placed on Transmission-Based Precautions? A. Encourage family and friends to call the client. B. Provide education on the mode of transmission of infection. C. Encourage the client to watch television. D. Ask a certified hospital chaplain to visit the client. - CORRECT ANSWER B. Provide education on the mode of transmission of infection. Education is the most appropriate and main intervention for addressing a client's feeling of isolation when placed on Transmission-Based Precautions. It is important to teach the client and family about the mode of transmission and mechanisms that prevent spread to others. The nurse needs to assess coping mechanisms that the client has used in the past. Encouraging phone calls and distraction activities like watching television may be effective interventions. Engaging a certified hospital chaplain to visit the client may help alleviate the client's stress, anxiety, or depression. A 14-year-old client has severe fatigue, swollen glands, and a low-grade fever. Which blood test result is used to confirm a diagnosis of mononucleosis? A. Decreased mononuclear leukocyte count B. Decreased leukocyte count C. Decreased neutrophil count D. Elevated erythrocyte sedimentation rate - CORRECT ANSWER C. Decreased neutrophil count In a client with mononucleosis, a white blood cell count would show a decrease in neutrophils. An abnormally large not decreased number of mononuclear leukocytes would be seen with mononucleosis. In most active infections, especially those caused by bacteria, the total leukocyte count is elevated, not decreased. An elevated erythrocyte sedimentation rate indicates infection, but does not specifically indicate mononucleosis. Which information does the nurse include when teaching a client about antibiotic therapy for infection? A. Take all antibiotics as prescribed, unless side effects develop. B. Take antibiotics until symptoms subside, and then stop taking the drugs. C. Take antibiotics when symptoms of infection develop. D. Share antibiotics with family members who develop the same infection. - CORRECT ANSWER A. Take all antibiotics as prescribed, unless side effects develop. Antibiotics should be taken as prescribed until they are gone. Teach the client about possible side effects and allergic manifestations. The provider must be contacted immediately if any side effects develop. Antibiotics must be taken until they are gone, even if the client feels better or when symptoms of infection appear. They should be taken only by the person for whom they are prescribed and not shared with anyone else. A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client? a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the client's right side and speak into the right ear. d. Allow the client to use a white board to ask questions. - CORRECT ANSWER ANS: C The temporal lobe contains the auditory center for sound interpretation. The client's hearing will be impaired in the left ear. The nurse should sit on the client's right side and speak into the right ear. The other interventions do not address the client's left temporal lobe damage. A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care? a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the client's legs. d. Assess the client's feet for wounds each shift. - CORRECT ANSWER ANS: B Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the client's problem. A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this client's teaching? a. "Place soft rugs in your bathroom to decrease pain in your feet." b. "Bathe in warm water to increase your circulation." given. A recent blood transfusion or current use of cardiac medications or oral contraceptives would not affect the angiography. A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement? a. Educate the client about strict bedrest after the procedure. b. Place an indwelling urinary catheter to closely monitor output. c. Obtain a prescription for intravenous fluids. d. Contact the provider to cancel the procedure. - CORRECT ANSWER ANS: C If a contrast medium is used, intravenous fluid may be given to promote excretion of the contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid replacement. The client will not require bedrest. Although urinary output should be monitored closely, there is no need for an indwelling urinary catheter. There is no need to cancel the procedure as long as actions are taken to protect the kidneys. A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure? a. Creatine phosphokinase (CPK) of 100 IU/L b. Atrioventricular graft c. Blood urea nitrogen (BUN) of 50 mg/dL d. Internal insulin pump - CORRECT ANSWER ANS: D Metal devices such as internal pumps, pacemakers, and prostheses interfere with the accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. An atrioventricular graft does not contain any metal. CPK and BUN levels have no impact on an MRI procedure. A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which statement should the nurse include in this client's teaching? a. "Avoid caffeine-containing substances for 12 hours before the test." b. "Drink at least 3 liters of fluid during the first 24 hours after the test." c. "Do not take your cardiac medication the morning of the test." d. "Remove your dentures and any metal before the test begins." - CORRECT ANSWER ANS: A Caffeine-containing liquids and foods are central nervous system stimulants and may alter the test results. No contrast is used; therefore, the client does not need to increase fluid intake. The client should take cardiac medications as prescribed. Metal does not have to be removed; this is done for magnetic resonance imaging. A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, "I am worried I will not be able to care for my young children." How should the nurse respond? a. "Caring for your children is a priority. You may not want to ask for help, but you have to." b. "Our community has resources that may help you with some household tasks so you have energy to care for your children." c. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?" d. "Give me more information about what worries you, so we can see if we can do something to make adjustments." - CORRECT ANSWER ANS: D Investigate specific concerns about situational or role changes before providing additional information. The nurse should not tell the client what is or is not a priority for him or her. Although community resources may be available, they may not be appropriate for the client. Consulting a psychologist would not be appropriate without obtaining further information from the client related to current concerns. A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this client's plan of care? a. Provide a call button that requires only minimal pressure to activate. b. Write the date on the client's white board to promote orientation. c. Ensure that the path to the bathroom is free from equipment. d. Encourage the client to season food to stimulate nutritional intake. - CORRECT ANSWER ANS: C Dementia and confusion are not common phenomena in older adults. However, physical impairment related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). Providing a call button, providing the date, and seasoning food do not address the client's impaired sensory perception. After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the client's understanding. Which client statement indicates a correct understanding of the teaching? a. "I must increase my fluids because of the dye used for the MRI." b. "My urine will be radioactive so I should not share a bathroom." c. "I can return to my usual activities immediately after the MRI." d. "My gag reflex will be tested before I can eat or drink anything." - CORRECT ANSWER ANS: C No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not needed and the client's urine would not be radioactive. The procedure does not impact the client's gag reflex. A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next? a. Touch the pin on the same area of the left hand. b. Contact the provider with the assessment results. c. Ask the client about current medications. d. Continue the assessment on the client's feet. - CORRECT ANSWER ANS: A If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse should continue the assessment on the left hand. This is a normal finding and does not need to be reported to the provider, but instead documented in the client's chart. Medications do not need to be assessed in response to this finding. The nurse should assess the left hand prior to assessing the feet. A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include in this client's discharge teaching? a. "Connect a light to flash when your door bell rings." b. "Label your faucet knobs with hot and cold signs." c. "Ask a friend to drive you to your follow-up appointments." d. "Use a natural gas detector with an audible alarm." - CORRECT ANSWER ANS: C Cerebellar function enables the client to predict distance or gauge the speed with which one is approaching an object, control voluntary movement, maintain equilibrium, and shift from one skilled movement to another in an orderly Which action should the nurse take next? a. Contact the provider with this abnormal finding. b. Assess bilateral legs for temperature and edema. c. Ask the client about pain in the lower leg and calf. d. Document the finding and continue the assessment. - CORRECT ANSWER ANS: A This finding indicates Babinski's sign. In clients older than 2 years of age, Babinski's sign is considered abnormal and indicates central nervous system disease. The nurse should notify the health care provider and other members of the health care team because further investigation is warranted. This finding does not relate to perfusion of the leg or to pain. This is an abnormal assessment finding and should be addressed immediately. A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How should the nurse document this client's assessment using the Glasgow Coma Scale shown below? a. 8 b. 10 c. 12 d. 14 - CORRECT ANSWER ANS: C The client opens his eyes to speech (Eye opening: To sound = 3), mumbles in response to questions (Verbal response: Inappropriate words = 3), and follows simple commands (Motor response: Obeys commands = 6). Therefore, the client's Glasgow Coma Scale score is: 3 + 3 + 6 = 12. A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Loss of smell b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex - CORRECT ANSWER ANS: B, D, E Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla. An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball. For which clinical manifestations that are related to a temporal lobe injury should the nurse assess? (Select all that apply.) a. Memory loss b. Personality changes c. Difficulty with sound interpretation d. Speech difficulties e. Impaired taste - CORRECT ANSWER ANS: A, C, D Wernicke's area (language area) is located in the temporal lobe and enables the processing of words into coherent thought as well as the understanding of written or spoken words. The temporal lobe also is responsible for the auditory center's interpretation of sound and complicated memory patterns. Personality changes are related to frontal lobe injury. Impaired taste is associated with injury to the parietal lobe. After administering a medication that stimulates the sympathetic division of the autonomic nervous system, the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Decreased respiratory rate b. Increased heart rate c. Decreased level of consciousness d. Increased force of contraction e. Decreased blood pressure - CORRECT ANSWER ANS: B, D Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart rate and the force of contraction. A medication that stimulates the sympathetic nervous system would also increase the client's respiratory rate, blood pressure, and level of consciousness. A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Diminished cognition - CORRECT ANSWER ANS: A, B, E The nurse should urgently communicate changes in a client's neurologic status, including a decrease in the Glasgow Coma Scale score, abnormal flexion or extension, changes in cognition or speech, and pinpointed, dilated, and nonreactive pupils. A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.) a. Ensure that an informed consent is present. b. Ask the client about any allergies. c. Evaluate the client's renal function. d. Auscultate bilateral breath sounds. e. Assess hematocrit and hemoglobin levels. - CORRECT ANSWER ANS: A, B, C A client who is scheduled to receive iodine-based contrast should be asked about allergies, especially allergies to iodine or shellfish. The client's kidney function should also be evaluated to determine if it is safe to administer contrast during the procedure. Finally, the nurse should ensure that an informed consent is present because all clients receiving iodine-based contrast must give consent. The CT will have no impact on the client's breath sounds or hematocrit and hemoglobin levels. Findings from these assessments will not influence the client's safety during the procedure. A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.) a. Long-term memory loss b. Slower processing time c. Increased sensory perception d. Decreased risk for infection e. Change in sleep patterns - CORRECT ANSWER ANS: B, E Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination. not used. A neurologic assessment and medication review are important, but the consent is the priority. A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the client's vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed. - CORRECT ANSWER ANS: C This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning. A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses. - CORRECT ANSWER ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea. A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week - CORRECT ANSWER ANS: C Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration. A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using "yes-or-no" questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms. - CORRECT ANSWER ANS: A Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. "Yes-or- no" questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up "words" often used by clients with sensory aphasia. A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information - CORRECT ANSWER ANS: B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 - 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery. A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication. - CORRECT ANSWER ANS: A These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication. A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache - CORRECT ANSWER ANS: A A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope. - CORRECT ANSWER ANS: A Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isn't useful because the client probably cannot help it. A referral might be a good idea, Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results. A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client's score to be 36. How should the nurse plan care for this client? a. The client will need near-total care. b. The client will need cuing only. c. The client will need safety precautions. d. The client will be discharged home - CORRECT ANSWER ANS: A This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the client's dependence. The client will need more than cuing to complete tasks. A home discharge may be possible, but this does not help the nurse plan care for a very dependent client. A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. "Increased pressure from the abscess can cause seizures." b. "Preventing febrile seizures with an abscess is important." c. "Seizures always occur in clients with brain abscesses." d. "This drug is used to sedate the client with an abscess." - CORRECT ANSWER ANS: A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation. A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device - CORRECT ANSWER ANS: B All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication. A client has a subarachnoid bolt. What action by the nurse is most important? a. Balancing and recalibrating the device b. Documenting intracranial pressure readings c. Handling the fiberoptic cable with care to avoid breakage d. Monitoring the client's phlebostatic axis - CORRECT ANSWER ANS: A This device needs frequent balancing and recalibration in order to read correctly. Documenting readings is important, but it is more important to ensure the device's accuracy. The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it, but ensuring the device's accuracy is most important. The phlebostatic axis is not related to neurologic monitoring. A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications - CORRECT ANSWER ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor. A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the client's record. What action by the nurse is best? a. Ask the client how long ago the clip was placed. b. Have the client sign an informed consent form. c. Inform the provider about the aneurysm clip. d. Reschedule the client for computed tomography. - CORRECT ANSWER ANS: A Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination. The client does not need to sign informed consent. The provider will most likely not know if the client can have an MRI with this clip. The nurse does not independently change the type of diagnostic testing the client receives. A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? a. Client who has been diagnosed with meningitis with a fever of 101° F (38.3° C) b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed - CORRECT ANSWER ANS: C The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t- PA, or the nurse could delegate checking on this client to another nurse. The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care - CORRECT ANSWER ANS: C This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care. After a stroke, a client has ataxia. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals. - CORRECT ANSWER ANS: A b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism - CORRECT ANSWER ANS: A, D, E Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures. A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings. - CORRECT ANSWER ANS: A, D, E "Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8. A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group. - CORRECT ANSWER ANS: A, C, D Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups. A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying a cool washcloth to the head b. Assisting the client to a position of comfort c. Keeping voices soft and soothing d. Maintaining low lighting in the room e. Providing antipyretics for fever - CORRECT ANSWER ANS: A, B, C, D The client with meningitis often has high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever. A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke - CORRECT ANSWER ANS: A, B, D, E Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral. A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement. - CORRECT ANSWER ANS: A, B, C, D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated. A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.) a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 year d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise - CORRECT ANSWER ANS: A, B After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding. A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home - CORRECT ANSWER ANS: B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity d. Ciprofloxacin (Ciloxan) - CORRECT ANSWER ANS: B Apraclonidine is an adrenergic agonist that binds to eye receptors to reduce the amount of aqueous humor in the eye, resulting in decreased intraocular pressure. This medication usually is administered to clients with glaucoma. Tobramycin, gentamicin, and ciprofloxacin are anti-infectives. Which statement indicates that a client understands why his cataract surgery is being done first on the eye with the poorest vision? a. "Insurance reimbursement dictates the timing of surgeries." b. "The eye with poorer vision is at greater risk for permanent damage." c. "The pressure in the poorer eye could increase, causing permanent damage." d. "If a complication arises in that eye, I will still have some vision in the better eye." - CORRECT ANSWER ANS: D The eye with the better sight is left alone until the outcome of the first surgery is known to reduce the chance that the client will lose sight in both eyes if complications arise from the surgery. The nurse is teaching a client about home care after cataract surgery. Which statement indicates that the client requires further teaching? a. "I am glad that I don't need an eye patch after the surgery." b. "I will try a cool compress to decrease the swelling around the operated eye." c. "Dark sunglasses will be necessary when I am in the sun." d. "Pain, nausea, and vomiting are normal after this surgery." - CORRECT ANSWER ANS: D Eye pain accompanied by nausea and vomiting is an indication of increased intraocular pressure and/or hemorrhage. This is an emergent situation and the surgeon must be contacted by the client. The other responses are correct. The client will not need an eye patch, cool compresses will decrease the slight swelling, and dark glasses are necessary outdoors until the pupil responds to sunlight. A client has been educated about activities that can increase intraocular pressure. Which statement indicates that the client requires further teaching? a. "I will avoid wearing tight shirt collars and ties." b. "I will take stool softeners daily to prevent straining." c. "I will try not to sneeze, cough, or blow my nose." d. "I will not put my arms above my head." - CORRECT ANSWER ANS: D Arm position does not influence intraocular pressure. All other activities listed decrease the incidence of increased intraocular pressure. The nurse assesses a client post-cataract surgery and finds white, dry, crusty drainage on the client's eyelid and lashes. What does the nurse do next? a. Obtain a specimen of the drainage for culture. b. Clean away the drainage and apply the prescribed drops. c. Contact the physician for an antibiotic order. d. Arrange for the client to be seen by the ophthalmologist today. - CORRECT ANSWER ANS: B White, dry, crusty drainage on the eyelid and lashes is expected after cataract surgery. Because the drainage is white and no other symptoms of infection are noted, a culture does not need to be done and an antibiotic will not be needed. Urgency is not an issue because this is an expected effect from the trauma of surgery. The physician does not need to be called. The nurse is assessing a client who wishes to be considered as a potential donor for corneal transplantation. Which medical diagnosis at the time of death excludes the client from consideration? a. Small cell lung cancer b. Chronic heart failure c. Profound nearsightedness d. History of detached retina - CORRECT ANSWER ANS: A Clients of any age may donate corneas as long as the corneas are clear and the client is free from infectious disease or cancer at the time of death. The other problems would not keep a client from donating corneas. The nurse assesses several clients. Which one is most likely to have secondary open-angle glaucoma? a. Client with gradual onset of blurred vision b. Client who has recently had eye surgery c. Client who sees halos around lights d. Client with reactive pupils and clear sclera - CORRECT ANSWER ANS: B Secondary open-angle glaucoma results from another condition that interferes with drainage of the aqueous humor such as recent eye surgery. Cataracts usually start with a slow onset of blurred vision but do not lead to secondary open-angle glaucoma. A late manifestation of primary open-angle glaucoma is seeing halos around lights; this is not considered secondary open-angle glaucoma. The client with reactive pupils and clear sclera has normal assessment findings, not related to secondary open-angle glaucoma. Which statement made by a client after corneal transplantation indicates a need for further teaching? a. "I will wear an eye shield at night for at least 1 month." b. "I will avoid bending at the waist and straining when moving my bowels." c. "I won't worry if I have increased tearing, because it is normal." d. "I'll notify the ophthalmologist if any signs of rejection occur." - CORRECT ANSWER ANS: C Aqueous humor can leak from the incision site if wound closure is incomplete. Any fluid coming from the eye in the early postoperative period needs to be checked by the provider. Which clinical manifestation alerts the nurse to the possibility of a vitreous humor hemorrhage? a. Presence of a red reflex b. Reddened whites of the eye c. Red haze or floaters in the line of vision d. Swelling of the upper and lower eyelids - CORRECT ANSWER ANS: C Mild seepage of blood into the vitreous humor causes the client's vision to have an overall red haze or floaters. With a vitreous humor hemorrhage, the red reflex is reduced. Reddened whites of the eye and swelling of the eyelids would indicate irritation and infection of the eye. The nurse is providing discharge teaching for a client with posterior uveitis. Which is the most important precaution for the nurse to teach the client? a. Correct technique for eyedrop instillation b. Clinical manifestations of retinal hemorrhage c. Correct technique for insertion of contact lenses d. Proper timing of opioid analgesics - CORRECT ANSWER ANS: A Treatment of posterior uveitis is symptomatic, with eyedrops used to dilate the pupil and decrease the inflammatory response. The client may have to instill eyedrops as frequently as every hour. This condition consists of inflammation of the retina—not a hemorrhage. Opioids are not prescribed to lessen the pain, but cool or warm compresses may be used for ocular pain.