Exam 2 Flashcards
(340 cards)
1
Q
Tumors of the small intestine are uncommon, of these approximately 64% are __________________.
A
malignant
2
Q
In patients with gastric cancer a _______may be used to evaluate for the presence of anemia.
A
CBC
3
Q
Most peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water.
T/F
A
TRUE
4
Q
Gastritis and _____________ from peptic ulcer disease are the two most common causes of upper GI tract bleeding.
A
Hemorrhage
5
Q
T/F: The vast majority of gastric cancers are acquired and not inherited.
A
TRUE
6
Q
T/F: The best time to teach a client to take proton pump inhibitors is 30 minutes before a meal.
A
TRUE
7
Q
T/F: The most common site for a peptic ulcer formation is in the pylorus.
A
FALSE- DU occurs most often in the first part of the duodenum or in the pre-pyloric region of the stomach (antrum)
8
Q
Currently, the most commonly used therapy for peptic ulcers is a combination of ____________, proton pump inhibitors, and bismuth salts that suppresses or eradicates H. pylori.
A
antibiotics
9
Q
_____________________ may occur a result any surgical procedure that involves the removal of a significant portion of the stomach or includes resection or removal of the pylorus.
A
dumping syndrome- also known as rapid gastric emptying.
Dumping syndrome occurs when your stomach empties its contents too quickly into your intestine.
10
Q
T/F: Acute gastritis is a prolonged inflammation due to benign or malignant ulcers of the stomach.
A
FALSE
Acute gastritis is usually caused by an irritant or infection, and can result in an acute upset stomach, but usually settles quickly with simple treatments when the cause is removed. Chronic gastritis is a condition in which the stomach lining is damaged long-term, often due to infection by H. pylori.
11
Q
Hemorrhagic strokes are primarily caused by __________ hemorrhage or subarachnoid hemorrhage.
A
intracranial
12
Q
Cerebral _____________ is a serious complication of subarachnoid hemorrhage and is a leading cause of morbidity and mortality in those who survive the initial hemorrhage.
A
vasospasm
13
Q
T/F: Disturbances in the left visual field and spatial–perceptual deficits are most frequently seen in patient with left hemispheric damage.
A
FALSE
14
Q
T/F: Approximately 80% of patients with stroke suffer severe shoulder pain preventing them from achieving balance and performing transfers and self-care activities.
A
TRUE
15
Q
An _____________ stroke, cerebrovascular disease, or “brain attack” is described as a sudden loss of function resulting from disruption of the blood supply to a part of the brain
A
ischemic
16
Q
T/F: An intracranial aneurysm is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall.
A
TRUE
17
Q
The main surgical procedure for selected patients with TIAs and mild stroke is _______ ______________.
A
carotid endarterectomy
18
Q
T/F: The goal for thrombolytic therapy for patients with ischemic stroke is to administer IV t-PA within 2 hours of the patient arriving to the ER.
A
FALSE:
rtPA should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke (Class I Recommendation, level of Evidence B)
19
Q
____________ is the most common cause of intracerebral hemorrhage.
A
Hypertension
20
Q
A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine. The nurse will explain that the medication will
A
inhibit development of stress ulcers
b/c stress of being in the accident
21
Q
A nurse is caring for a client who is scheduled for a colonoscopy and whose preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation?
A
Inflammatory bowel disease
don’t want to put more stress on bowels
22
Q
The nurse will anticipate preparing an older patient who is vomiting “coffee-ground” emesis for
A
endoscopy
23
Q
The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute GIB. Which assessment finding is important for the nurse to communicate to the health care provider?
bowel sounds are hyperactive in all four quadrants
NG suction is returning coffee-ground material
patient’s lungs have crackles audible to the midchest
patient’s BP has increased to 142/74 mm Hg
A
patient’s lungs have crackles audible to the midchest
prioritization q: might indicate that pt is becoming fluid overload and not exchanging o2 for co2; Not NG suction w/ coffee material b/c this is EXPECTED
24
Q
A female client has presented to the emergency department with right upper quadrant pain; the health care provider has ordered abdominal ultrasound to rule out cholecystitis. The client expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond?
A
“Abdominal ultrasound poses no known safety risks of any kind.”
25
After the nurse teaches a patient with GERD about recommended dietary modifications, which statement by the patient indicates that the teaching has been effective?
“I will have to use herbal teas instead of caffeinated drinks.”
26
A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize?
Strategies for avoiding irritating foods and beverages
27
Which patient should the nurse assess first after receiving change-of-shift report? The patient:
with nausea who has a dose of metoclopramide due
who is crying after receiving a diagnosis of esophageal cancer
with esophageal varices who has a blood pressure of 99/58 mm Hg
admitted yesterday with gastrointestinal bleeding (GIB) who has melena
with esophageal varices who has a blood pressure of 99/58 mm Hg
standard prioritization question- dropping low, and melena would be an expected outcome from GI bleed
28
A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure?
Colonoscopy
| polyps are in the colon
29
Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes?
Homonymous hemianopsia
Explanation:
Homonymous hemianopsia occurs with occipital lobe tumors.
30
A client's sigmoidoscopy has been successfully completed and the client is preparing to return home. What teaching point should the nurse include in the client's discharge education?
The client can resume a normal routine immediately.
30
A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:
alcohol abuse and smoking
31
A client is prescribed a histamine (H2)-receptor antagonist. The nurse understands that this might include which medication(s)? Select all that apply.
Nizatidine
Famotidine
Cimetidine
H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions.
32
A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccupping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems?
A client with acute gastritis may have a rapid onset of symptoms, including abdominal discomfort, headache, lassitude, nausea, anorexia, vomiting, and hiccupping, which can last from a few hours to a few days. Acute gastritis is often caused by dietary indiscretion-a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms
33
A client is in the hospital for the treatment of peptic ulcer disease. The client reports vomiting and a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate?
Perforation of the peptic ulcer
Explanation:
Signs and symptoms of perforation include the following: Sudden, severe upper abdominal pain (persisting and increasing in intensity), which may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, indicating shock.
34
A client with peptic ulcer disease has a blood pressure of 88/40 mm Hg, dizziness, and nausea. Which complication will the nurse suspect is occurring with this client?
Bleeding from the ulcer
Explanation:
Bleeding peptic ulcers account for 27% to 40% of all upper GI bleeds and it may be manifested by hematemesis or melena. Faintness or dizziness and nausea may precede or accompany bleeding. A low blood pressure could indicate active bleeding
35
The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client makes which statement?
"I have learned some relaxation strategies that decrease my stress."
Explanation:
The nurse assists the client to identify stressful or exhausting situations. A hectic lifestyle and an irregular schedule may aggravate symptoms and interfere with regular meals taken in relaxed settings along with the regular administration of medications. The client may benefit from regular rest periods during the day, at least during the acute phase of the disease. Biofeedback, hypnosis, behavior modification, massage, or acupuncture may be helpful.
36
When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain in the right shoulder. What is the initial appropriate action by the nurse?
Assess the client's abdomen and vital signs.
Explanation:
Signs and symptoms of perforation includes sudden, severe upper abdominal pain (persisting and increasing in intensity); pain may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm. The nurse should assess the vital signs and abdomen prior to notifying the physician. Irrigation of the NG tube should not be performed because the additional fluid may be spilled into the peritoneal cavity, and the client should be placed in a position of comfort, usually on the side with the head slightly elevated.
37
A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. What will the nurse suspect?
Vasomotor symptoms associated with dumping syndrome
Explanation:
Early manifestations of dumping syndrome occur 15 to 30 minutes after eating. Signs and symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, diarrhea, nausea, and the desire to lie down.
38
A client is recovering from gastric surgery. Toward what goal should the nurse progress the client’s enteral intake?
Six small meals daily with 120 mL fluid between meals
Explanation:
After the return of bowel sounds and removal of the nasogastric tube, the nurse may give fluids, followed by food in small portions. Foods are gradually added until the client can eat six small meals a day and drink 120 mL of fluid between meals.
39
Which of the following appears to be a significant factor in the development of gastric cancer?
Diet
Explanation:
Diet seems to be a significant factor: a diet high in smoked, salted, or pickled foods and low in fruits and vegetables may increase the risk of gastric cancer.
40
Which is a true statement regarding gastric cancer?
Most clients are asymptomatic during the early stage of the disease.
Explanation:
Most clients are asymptomatic during the early stage of the disease. Men have a higher incidence of gastric cancer. The prognosis is poor because the diagnosis is usually made late because most clients are asymptomatic during the early stage. Most cases of gastric cancer are discovered only after local invasion has advanced or metastases are present.
41
A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description?
Black and tarry
Explanation:
Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffee-ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.
42
The nursing student approaches his instructor to discuss the plan of care for his client diagnosed with peptic ulcer disease. The student asks what is the most common site for peptic ulcer formation? The instructor would state which one of the following?
Duodenum
Explanation:
Peptic ulcers occur mainly in the gastroduodenal mucosa because this tissue cannot withstand the digestive action of gastric acid (HCl) and pepsin.
43
Peptic ulcer disease occurs more frequently in people with which blood type?
O
Explanation:
People with blood type O are more susceptible to peptic ulcers than those with blood type A, B, or AB.
44
A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.)
“It can be caused by ingestion of strong acids.”
“You may have ingested some irritating foods.”
“Is it possible that you are overusing aspirin.”
Explanation:
Acute gastritis is often caused by dietary indiscretion—the person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate.
45
A client is prescribed tetracycline to treat peptic ulcer disease. Which instruction would the nurse give the client?
"Be sure to wear sunscreen while taking this medicine."
Explanation:
Tetracycline may cause a photosensitivity reaction in clients. The nurse should caution the client to use sunscreen when taking this drug. Dairy products can reduce the effectiveness of tetracycline, so the nurse should not advise him or her to take the medication with milk. GI upset is possible with tetracycline administration. Administration of tetracycline does not necessitate driving restrictions.
46
The nurse recognizes that the client diagnosed with a duodenal ulcer will likely experience
pain 2 to 3 hours after a meal.
Explanation:
The client with a duodenal ulcer often awakens between 1 and 2 with pain, and ingestion of food brings relief. Vomiting is uncommon in the client with duodenal ulcer. Hemorrhage is less likely in the client with duodenal ulcer than in the client with gastric ulcer. The client with a duodenal ulcer may experience weight gain.
47
A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed?
A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum.
Explanation:
A Billroth I procedure involves removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. A vagotomy severs the vagus nerve; a Billroth I procedure may be performed in conjunction with a vagotomy. If the remaining part of the stomach is anastomosed to the jejunum, the procedure is a Billroth II.
48
A client who had a Roux-en-Y bypass procedure for morbid obesity ate a chocolate chip cookie after a meal. After ingestion of the cookie, the client reported cramping pains, dizziness, and palpitation. After having a bowel movement, the symptoms resolved. What should the nurse educate the client about regarding this event?
Dumping syndrome
Explanation:
Dumping syndrome is an unpleasant set of vasomotor and GI symptoms that occur in up to 76% of patients who have had bariatric surgery. Early symptoms include a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. These symptoms resolve once the intestine has been evacuated (i.e., with defecation).
49
During a home visit the nurse notes that a client recovering from peptic ulcer disease is experiencing cool clammy skin and has a heart rate of 96 beats a minute. Which action will the nurse take?
Notify the primary health care provider.
Explanation:
The client with peptic ulcer disease is demonstrating signs of hemorrhage which include cool skin and tachycardia. The health care provider should be immediately notified. The client should not be given any additional medication. A warm beverage could enhance bleeding. It is inappropriate to provide any teaching while the client is experiencing an acute condition.
50
Which of the following is the most successful treatment for gastric cancer?
Removal of the tumor
Explanation:
There is no successful treatment for gastric carcinoma except removal of the tumor. If the tumor can be removed while it is still localized to the stomach, the patient may be cured. If the tumor has spread beyond the area that can be excised, cure is less likely.
51
A client diagnosed with a peptic ulcer says, “Now I have something else I have to worry about.” Which actions will the nurse take to help reduce the client’s anxiety? Select all that apply.
Interact with the client in a relaxed manner.
Help identify the client’s current stressors.
Discuss potential coping techniques with the client.
Offer information about relaxation methods.
Explanation:
A client with a peptic ulcer may have a problem with anxiety. To help reduce the client’s anxiety, the nurse should interact with the client in a relaxed manner and help the client identify stressors. The nurse can also discuss potential coping techniques and offer information about relaxation methods. Stating that medication will solve the problem may not be sufficient if stress and anxiety are contributors to the development of the ulcer.
52
A client with peptic ulcer disease must begin triple medication therapy. For how long will the client follow this regimen?
10 to 14 days
Explanation:
Recommended therapy for 10 to 14 days includes triple therapy with two antibiotics (e.g., metronidazole [Flagyl] or amoxicillin [Amoxil] and clarithromycin [Biaxin]) plus a proton pump inhibitor (e.g., lansoprazole [Prevacid], omeprazole [Prilosec], or rabeprazole [Aciphex]), or quadruple therapy with two antibiotics (metronidazole and tetracycline) plus a proton pump inhibitor and bismuth salts (Pepto-Bismol).
53
A client with gastric ulcers caused by H. pylori is prescribed metronidazole. Which client statement indicates to the nurse that teaching about this medication was effective?
“It might cause a metallic taste in my mouth.”
Explanation:
Metronidazole is a synthetic antibacterial and antiprotozoal agent that assists with eradicating H. pylori bacteria in the gastric mucosa when given with other antibiotics and proton pump inhibitors. This medication may cause a metallic taste in the mouth. It should not be taken with anticoagulants as it will increase the blood thinning effects of warfarin. Alcohol should be avoided while taking this medication. This medication may cause anorexia and not an increased appetite.
54
A client with a peptic ulcer asks, “How does something that goes into my lungs, like smoking, affect my stomach?” Which response by the nurse is most appropriate?
“Smoking reduces the amount of bicarbonate needed to buffer stomach acid.”
Explanation:
Smoking decreases the secretion of bicarbonate from the pancreas into the duodenum, resulting in increased acidity of the duodenum. Continued smoking is also associated with delayed healing of peptic ulcers. Even though smoking is overall bad for health and contains irritants that affect all body organs, these are not the reasons why the client should stop smoking. Rather than decreasing gastric acid secretion, smoking increases gastric acid secretion.
55
A client is preparing for discharge to home following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal?
Slows gastric emptying
Explanation:
Dumping syndrome is a common complication following subtotal gastrectomy. To avoid the rapid emptying of stomach contents, resting after meals can be helpful. Promoting rest after a major surgery is helpful in recovery but not the reason for resting after meals. Following this type of surgery, clients will have a need for vitamin B12 supplementation due to absence of production of intrinsic factor in the stomach. Resting does not increase absorption of B12 or remove tension on suture line.
56
A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, labored breathing, and appears to be confused. Which complication has the client most likely developed?
Hemorrhage
Explanation:
Signs of hemorrhage following surgery include cool skin, confusion, increased heart rate, labored breathing, and blood in the stool.
57
Clients with Type O blood are at higher risk for which of the following GI disorders?
Duodenal ulcers
Explanation:
Familial tendency also may be a significant predisposing factor. People with blood type O are more susceptible to peptic ulcers than are those with blood type A, B, or AB. Blood type is not a predisposing factor for gastric cancer, esophageal varices, and diverticulitis.
58
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
drink liquids only between meals.
Explanation:
A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in the prevention of rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.
59
Which medication classification represents a proton (gastric acid) pump inhibitor?
Omeprazole
Explanation:
Omeprazole decreases gastric acid by slowing the hydrogen-potassium adenosine triphosphatase pump on the surface of the parietal cells. Sucralfate is a cytoprotective drug. Famotidine is a histamine-2 receptor antagonist. Metronidazole is an antibiotic, specifically an amebicide.
60
A stroke caused by the occlusion of an artery leading to infarction is:
an ischemic stroke
61
T/F: You can easily tell by the symptoms whether the patient had an ischemic or hemorrhagic stroke
FALSE- need CT scan to tell which it is
62
T/F: Motor deficits are on the opposite side of the body as to where the brain damage occurred
True
63
The most common type of stroke is:
thrombotic ischemic stroke
64
If you suspect a patient is having a TIA, the nurse will closely monitor to see if the symptoms resolve within one hour.
FALSE-
| I think because you have no idea if it is transient so you would just start to implement stroke tx
65
Which of the following is true of dysarthria?
It affects the muscles that control speech
| dysarthria is slurred speech
66
Which of the following is NOT an appropriate intervention for a patient with a hemorrhagic stroke?
Anticoagulants
| Can cause more head bleeding!
67
The most important modifiable risk factor for stroke is
Hypertension
68
A "Brain Attack" is called in the ED. Which diagnostic test would the nurse educate the patient about?
```
Computed tomography (CT) of the Head
used to dx ischemic from hemorrhagic
```
69
A form of aphasia where small words are omitted and short phrases take effort but make sense:
Expressive aphasia
70
Which of the following interventions will be used to treat bladder control issues in the stroke patient? (Select all that apply):
Ensure adequate fluid intake
Insert indwelling Foley catheter
Palpate for bladder distention
Toileting every 2 hours
Ensure adequate fluid intake
Palpate for bladder distention
Toileting every 2 hours
*no foley
71
The nurse is educating a patient that experienced a transient ischemic attack (TIA). More education is needed based on which of the following statements?
The symptoms of a TIA are different from a stroke
| this is wrong so he must be corrected and provided more education
72
Considerations for a patient with dysphagia following a stoke include which of the following (Select all that apply):
Assess level of consciousness, gag reflex and swallowing ability
Avoid liquids or use thickeners
Perform mouth care before feeding
Place food on affected side of mouth
Assess level of consciousness, gag reflex and swallowing ability
Avoid liquids or use thickeners
Perform mouth care before feeding
73
Signs of a possible stroke include (Select all that apply)
Face Drooping
Arm Weakness
Speech Difficulty
Visual Disturbances
74
Which of the following is the most in-depth assessment tool for a stroke patient?
NIHSS (National Institutes of Health Stroke Scale)
75
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?
immediately
Explanation:
Beginning basic rehabilitation during the acute phase is an important nursing function. Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.
76
The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:
Right-sided paralysis.
Explanation:
A left hemispheric stroke will cause right-sided weakness or paralysis. Because upper motor neurons decussate, a disturbance on one side of the body can cause damage on the opposite side of the brain. Refer to Box 47-2 in the text.
77
Which terms refers to blindness in the right or left half of the visual field in both eyes?
Homonymous hemianopsia
78
________ refers to a defect in vision in a specific area in one or both eyes
Scotoma
79
_______ refers to double vision or the awareness of two images of the same object occurring in one or both eyes
Diplopia
80
_________ refers to rhythmic, involuntary movements or oscillations of the eyes.
Nystagmus
81
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy?
International normalized ratio greater than 2
Explanation:
The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.
82
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal
Explanation:
If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.
83
A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke?
severe exploding headache
Explanation:
A hemorrhagic stroke is often characterized by a severe headache (commonly described as the "worst headache ever") or as "exploding." Weakness and speech issues are more commonly associated with an ischemic stroke.
84
Which disturbance results in loss of half of the visual field?
Homonymous hemianopsia
Explanation:
Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent.
85
Anisocoria is______ O.o
unequal pupils.
86
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?
"The client is unaware of his left side. You should approach him on the right side."
Explanation:
The client is experiencing unilateral neglect and is unaware of his left side. The nurse should advise the family to approach him on his unaffected (right) side. Approaching the client on the affected side would be counterproductive. It's too premature to make the determination whether this condition will be permanent.
87
After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider?
Diastolic pressure of 110 mm Hg
Explanation:
A diastolic pressure reading of over 105 mm Hg warrants notifying the health care provider. The other choices are within normal range.
88
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, “One minute he is laughing, and the next he’s crying; I just don’t understand what’s wrong with him.” Which statement is the best response by the nurse?
“Emotional lability is common after a stroke, and it usually improves with time.”
Explanation:
This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client’s laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse’s concerns.
89
A client is diagnosed with an ischemic stroke. For which reason(s) would the nurse question the use of tissue plasminogen activator (tPA) for this client? Select all that apply.
Platelet count 95,000/mm3
Systolic blood pressure 198 mm Hg
Diastolic blood pressure 120 mm Hg
Received low-molecular weight heparin injections twice a day
Explanation:
There are specific criteria for the administration of tissue plasminogen activator (tPA). The administration of this medication is to be questioned if the platelet count is less than 100,000/mm3. The systolic blood pressure has to be less than or equal to 185 mm Hg. The diastolic blood pressure has to be less than or equal to 110 mm Hg. Lastly, the client is not to have received low-molecular weight heparin during the past 24 hours. The prothrombin time needs to be less than or equal to 15 seconds for eligibility.
90
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?
Ischemic
Explanation:
Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety.
91
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
Every 15 minutes
Explanation:
Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.
92
An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?
Three hours
Explanation:
Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.
93
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
Transient ischemic attack
Explanation:
A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
94
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?
Left visual field deficit
Explanation:
A left visual field deficit is a common clinical manifestation of a right hemispheric stroke.
95
phasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a ________ hemispheric stroke.
left
96
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output
Explanation:
The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output.
97
A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?
Hemiplegia, seizures, and decreased level of consciousness
Explanation:
Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms.
98
A patient comes to the clinic with the complaint, “I think I have an ulcer.” What is a characteristic associated with peptic ulcer pain that the nurse should inquire about?
Burning sensation localized in the back or mid-epigastrium
Feeling of emptiness that precedes meals from 1 to 3 hours
Severe gnawing pain that increases in severity as the day progresses
99
A client recovering from a total gastrectomy has a low red blood cell count. Which medication will the nurse expect to be prescribed for this client?
Vitamin B12 injections
Explanation:
Intrinsic factor is secreted by the parietal cells in the stomach, which binds to vitamin B12 so it can be absorbed in the ileum. With the loss of some parietal cells, there is a deficiency in vitamin B12, which leads to a decreased production of red blood cells or pernicious anemia. Treatment would be vitamin B12 injections for life. Oral iron tablets would be prescribed for iron deficiency anemia. Erythropoietin injections would be prescribed for anemia caused by kidney disease. The client is not actively bleeding and would not need transfusions of packed RBCs.
100
A client has given a confirmed diagnosis of gastric cancer. Which procedure is important to assess tumor depth?
Endoscopic ultrasound
Explanation:
Esophagogastroduodenoscopy for biopsy and cytologic washings is the diagnostic study of choice, and a barium x-ray examination of the upper GI tract may also be performed. Endoscopic ultrasound is an important tool to assess tumor depth and any lymph node involvement. Pelvic ultrasound is not used to confirm the diagnosis of gastric cancer.
101
A client with an H. pylori infection asks why bismuth subsalicylate is prescribed. Which response will the nurse make?
“It aids in the healing of the stomach lining.”
Explanation:
Bismuth subsalicylate suppresses H. pylori bacteria in the gastric mucosa and assists with healing of mucosal ulcers. It does not affect digestion, enhance the function of the pyloric sphincter, or propel food from the stomach into the duodenum.
102
A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer.
Nizatidine Cimetidine Famotidine Omeprazole
Omeprazole
Explanation:
Omeprazole (Prilosec) is a proton pump inhibitor that, if used according to the health care provider's directions, will result in healing in 90% of patients. The other drugs are H2 receptor antagonists that need to be used for 6 weeks.
103
A health care provider suspects that a client has peptic ulcer disease. With which diagnostic procedure would the nurse most likely prepare to assist?
Endoscopy
Explanation:
Barium study of the upper GI tract may show an ulcer; however, endoscopy is the preferred diagnostic procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions. Through endoscopy, a biopsy of the gastric mucosa and of any suspicious lesions can be obtained. Endoscopy may reveal lesions that, because of their size or location, are not evident on x-ray studies. Less invasive diagnostic measures for detecting H. pylori include serologic testing for antibodies against the H. pylori antigen, stool antigen test, and urea breath test.
104
Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following?
Mental confusion
Explanation:
Signs of bleeding include tachycardia, tachypnea, hypotension, mental confusion, thirst, and oliguria.
105
Which medication is classified as a histamine-2 receptor antagonist?
Famotidine
Explanation:
Famotidine is a histamine-2 receptor antagonist. Lansoprazole and esomeprazole are proton pump inhibitors (PPIs). Metronidazole is an antibiotic.
106
The nurse in the ED admits a client with suspected gastric outlet obstruction. The client’s symptoms include nausea and vomiting. The nurse anticipates that the physician will issue which order?
Nasogastric tube insertion
Explanation:
The nurse anticipates an order for nasogastric tube insertion to decompress the stomach. Pelvic x-ray, oral contrast, and stool specimens are not indicated at this time.
107
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?
Neurovascular system
Explanation:
The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. Continual cardiovascular assessment is important but not the main focus of assessment. Respiratory compromise is not noted as a concern. The symptoms exhibited are not from an endocrine dysfunction.
108
Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes?
Smoking
Explanation:
Modifiable risk factors for TIAs and ischemic stroke include hypertension, diabetes, cardiac disease, smoking, and excessive alcohol consumption.
109
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?
Left visual field deficit
Explanation:
A left visual field deficit is a common clinical manifestation of a right hemispheric stroke
110
Aphasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a______ hemispheric stroke.
left
111
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?
Thrombolytic therapy has a time window of only 3 hours.
Explanation:
Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system.
112
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?
Establishing eye contact
Explanation:
The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.
113
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
Heparin sodium
Explanation:
Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the healthcare provider may use dexamethasone (Decadron) to decrease cerebral edema and pressure, methyldopa (Aldomet) to reduce blood pressure, and phenytoin (Dilantin) to prevent seizures.
114
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action?
Form understandable words and comprehend spoken words
Explanation:
Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to communicate effectively with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.
115
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
Transient ischemic attack
Explanation:
A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
116
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?
Intracranial hemorrhage
Explanation:
Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
117
An emergency department nurse understands that a 110-lb (50-kg) recent stroke victim will receive at least the minimum dose of recombinant tissue plasminogen activator (t-PA). What minimum dose will the client receive?
45 mg
Explanation:
The client is weighed to determine the dose of t-PA. Typically, two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg. 50 kg X 0.9 mg= 45 mg dose
118
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is
aspirin.
Explanation:
If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
119
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
Left-sided cerebrovascular accident (CVA)
Explanation:
When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.
120
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal
Explanation:
If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.
121
A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially?
6.3 mg
Explanation:
A person who weighs 154 lbs weighs 70 kg. To calculate total dosage, multiply 70 × 0.9 mg/kg = 63 mg. Ten percent of the calculated dose is given as an IV bolus over 1 minute. The remaining dose (90%) is given IV over 1 hour via an infusion pump. So initially the nurse gives 10% (6.3 mg) over 1 minute.
122
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern?
Remove throw rugs and electrical cords from home environment.
Explanation:
Client and family teaching is essential and focuses on the following points: Remove throw rugs, clutter, and electrical cords from the client's home environment to reduce the potential for falls. Although the other interventions may be appropriate, they are not as directly related to reducing fall risk.
123
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?
Face the client and establish eye contact.
Explanation:
When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. The nurse should use short phrases, not one long sentence, and give the client time between phrases to understand what is being said. Keeping extraneous and background noise such as the television to a minimum helps the client concentrate on what is being said. It isn't necessary to speak in a louder or softer voice than normal.
124
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Severe headache and early change in level of consciousness
Explanation:
The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.
125
Which of the following is the initial diagnostic in suspected stroke?
Noncontrast computed tomography (CT)
Explanation:
An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.
126
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client’s symptoms?
impaired cerebral circulation
Explanation:
TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.
127
A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is:
unknown.
Explanation:
Although cluster headaches can be triggered by vasodilating agents, the cause of cluster headaches is unknown.
128
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?
4:00 p.m.
Explanation:
Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.
129
A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?
cardio embolic
130
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia
Explanation:
Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact
131
______ is a failure to recognize familiar objects perceived by the senses
Agnosia
132
______ refers to disturbances in writing intelligible words
Agraphia
133
_______ is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate.
Perseveration
134
The etiology of cancer of the colon and rectum is predominantly _____________________, a malignancy arising from the epithelial lining of the intestine.
adenocarcinoma
135
_____________________is a chronic functional disorder characterized by recurrent abdominal pain associated with diarrhea, constipation, or both.
Irritable bowel syndrome
136
T/F: Decompression of the bowel through a nasogastric tube is necessary for all patients with small bowel obstruction.
True
137
T/F: Diverticula may occur anywhere in the small intestine or colon, but most commonly occur in the ascending colon.
False- They are found most often in the lower part of the large intestine (colon).
138
T/F: Diarrhea is defined as the increased frequency of more than three bowel movements per day.
True
139
Straining at stool initiates the ____________ maneuver that results in a potentially dangerous increase in BP.
valsalva
140
T/F: The patient with irritable bowel syndrome (IBS) should select foods low in fiber in order to minimize intestinal irritation
False- The best fiber choices when you have Crohn's are foods that contain soluble fiber. Soluble fiber soaks up extra fluid in your gut. Foods rich in soluble fiber can help you slow down your digestion and ease diarrhea. The other kind of fiber, insoluble fiber, can boost the amount of water in your gut.
141
In Crohn's disease, the common clinical manifestations include abdominal pain and _____________.
diarreha
142
T/F: Celiac disease is a disorder of malabsorption caused by an autoimmune response to consumption of products that contain the protein gluten.
True
143
_______________, the most common cause of acute surgical abdomen in the United States, is the most common reason for emergency abdominal surgery.
appendicitis
144
Post appendectomy, a nurse should assess the patient for abdominal rigidity and tenderness, fever, loss of bowel sounds, and tachycardia, all clinical signs of:
Peritonitis
Explanation:
Peritonitis is inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera. Peritonitis is typically a life-threatening emergency that requires prompt surgical intervention, and typically involves postoperative critical care monitoring due to the risk of sepsis, organ failure, and subsequent infections.
145
The nurse is assessing a client for constipation. Which review should the nurse conduct first to identify the cause of constipation?
Usual pattern of elimination
Explanation:
Constipation has many possible causes and assessing the client's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.
146
The nurse is talking with a group of clients who are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?
Change in bowel habits
Explanation:
The chief characteristic of cancer of the colon is a change in bowel habits, such as alternating constipation and diarrhea. Excess gas, daily bowel movements, and abdominal cramping when having a bowel movement are not indicators of colon cancer.
147
An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to?
Hypokalemia
Explanation:
The older client taking digitalis must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the client to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.
148
A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client?
Suggest fluid intake of at least 2 L/day
Explanation:
The nurse should suggest a fluid intake of at least 2 L/day to help the client avoid constipation. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the client to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the client to keep a record of food intake in case of diarrhea, because this helps identify specific foods that irritate the gastrointestinal tract.
149
A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?
Sigmoidoscopy
Explanation:
Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer.
150
A nurse is preparing a presentation for a local community group of older adults about colon cancer. What would the nurse include as the primary characteristic associated with this disorder?
A change in bowel habits
Explanation:
Although abdominal distention and blood in the stool (frank or occult) may be present, the chief characteristic of cancer of the colon is a change in bowel habits, such as alternating constipation and diarrhea. Abdominal pain is a late sign.
151
The nurse is performing a rectal assessment and notices a longitudinal tear or ulceration in the lining of the anal canal. The nurse documents the finding as which condition?
Anal fissure
Explanation:
Fissures are usually caused by the trauma of passing a large, firm stool or from persistent tightening of the anal canal secondary to stress or anxiety (leading to constipation). An anorectal abscess is an infection in the pararectal spaces. An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus. A hemorrhoid is a dilated portion of vein in the anal canal.
152
Which characteristic is a risk factor for colorectal cancer?
Familial polyposis
Explanation:
Family history of colon cancer or familial polyposis is a risk factor for colorectal cancer. Age older than 40 years and a high-fat, high-protein, low-fiber diet are risk factors for colorectal cancer. A history of skin cancer is not a recognized risk factor for colorectal cancer.
153
Which is the most common presenting symptom of colon cancer?
Change in bowel habits
154
A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?
Test all stools for occult blood.
Explanation:
Blood in the stools is one of the warning signs of colorectal cancer. The nurse should plan on checking all stools for both frank and occult blood. The blood in the stool is coming from the colon or rectum; administering an ointment wouldn't help decrease the bleeding. Preparing a client for a gastrostomy tube isn't appropriate when diagnosing colorectal cancer. Colorectal cancer is usually painless; administering opioid pain medication isn't needed
155
The nurse is irrigating a colostomy when the patient says, “You will have to stop, I am cramping so badly.” What is the priority action by the nurse?
Clamp the tubing and give the patient a rest period.
Explanation:
When irrigating a colostomy, the nurse should allow tepid fluid to enter the colon slowly. If cramping occurs, the nurse should clamp off the tubing and allow the patient to rest before progressing. Water should flow in over a 5- to 10-minute period.
156
A patient is not having daily bowel movements and has begun taking a laxative for this problem. What should the nurse educate the patient about regarding laxative use?
Laxatives should not be routinely taken due to destruction of nerve endings in the colon.
Explanation:
Laxative abuse, particularly the anthracene derivatives such as senna and cascara, can lead to destruction of the nerves of the colon that are essential for normal peristalsis (Apau, 2010a).
157
A client is admitted to the emergency department with reports right lower quadrant pain. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the health care provider immediately?
White blood cell (WBC) count 22.8/mm3
Explanation:
The nurse should report the elevated WBC count. This finding, which is a sign of infection, indicates that the client's appendix might have ruptured. Hematocrit of 42%, serum potassium of 4.2 mEq/L, and serum sodium of 135 mEq/L are within normal limits. Alterations in these levels don't indicate appendicitis.
158
A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and board-like. What complication does the nurse determine may be occurring at this time?
Peritonitis
Explanation:
Lack of bowel motility typically accompanies peritonitis. The abdomen feels rigid and board-like as it distends with gas and intestinal contents. Bowel sounds typically are absent. The diagnosis of acute appendicitis correlates with the symptoms of rupture of the appendix and peritonitis. A paralytic ileus and gas alone do not produce these symptoms.
159
A client informs the nurse of having abdominal pain that is relieved when having a bowel movement. The health care provider diagnosed the client with irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder?
Chronic constipation with sporadic bouts of diarrhea
Explanation:
Most clients with irritable bowel syndrome (IBS) describe having chronic constipation with sporadic bouts of diarrhea. Some report the opposite pattern, although less commonly. Most clients experience various degrees of abdominal pain that defecation may relieve. Weight usually remains stable, indicating that when diarrhea occurs, malabsorption of nutrients does not accompany it. Stools may have mucus, but blood is not usually found because the bowel is not locally inflamed. The sleep is not disturbed from abdominal pain.
160
The nurse is preparing a client for a test that involves inserting a thick barium paste into the rectum with radiographs taken as the client expels the barium. What test will the nurse prepare the client for?
Defecography
Explanation:
In defecography, a thick barium paste is inserted into the rectum. Radiographs are taken as the client expels the barium to determine whether there are any anatomic abnormalities or problems with the muscles surrounding the anal sphincter. A KUB will not determine this. Colonic transit studies are used to determine how long it takes for food to travel through the intestines. Abdominal radiography will show the structure but does not determine the muscle ability surrounding the anal sphincter.
161
What information should the nurse include in the teaching plan for a client being treated for diverticulosis?
Drink at least 8 to 10 large glasses of fluid every day
Explanation:
The nurse should instruct a client with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The client should include unprocessed bran in the diet because it adds bulk, and should avoid the use of laxatives or enemas except when recommended by the physician. In addition, regular exercise should be encouraged if the client's current lifestyle is somewhat inactive.
162
Which of the following is the most common symptom of a polyp?
Rectal bleeding
Explanation:
The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis.
163
In women, which of the following types of cancer exceeds colorectal cancer?
Breast
Explanation:
In women, only incidences of breast cancer exceed that of colorectal cancer. In men, only incidences of prostate cancer and lung cancer exceed that of colorectal cancer.
164
T/F: Trigeminal neuralgia (Tic Douloureux) is a condition of the 12th cranial nerve characterized by paroxysms of sudden pain.
FALSE- 5th cranial nerve
165
Bell palsy is caused by the unilateral inflammation of the __________ cranial nerve which results in weakness or paralysis of the facial muscles on the affected side.
7th
166
T/F: Meningeal irritation is suspected when a patient exhibits a negative, bilateral Kernig sign.
FALSE- they would have a positive
167
The primary vector in North America that is responsible for transmitting several types of viruses that cause encephalitis is the _______________.
mosquito
168
T/F: The oral disease-modifying agent fingolimod, recently approved by the FDA, has shown to decrease relapse rates in multiple sclerosis by approximately 50%.
TRUE
169
T/F: Herpes simplex virus is the most common cause of acute encephalitis in the United States.
TRUE
170
Most patients diagnosed with ________ _________ have a relapsing-remitting course.
multiple sclerosis
171
___________ syndrome is an autoimmune attack on myelin, a complex substance that covers nerves.
Guillain-Barré
172
T/f: The initial manifestation of myasthenia gravis in most patients involves the ocular muscles.
True
173
The most common predisposing conditions for brain abscesses among immunocompetent adults are otitis media and ________________.
rhinosinusitis
174
A client's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the client's laboratory studies, what finding is most closely associated with this diagnosis?
Increased serum bilirubin
175
A nurse is preparing to provide care for a client whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the client's stools will have what characteristics?
Watery with blood and mucus
176
A patient admitted with a peptic ulcer has a NGT tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take first?
Check the vital signs
177
A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?
Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure.
178
A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize?
Ineffective Tissue Perfusion Related to Bowel Ischemia
179
Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching?
Oatmeal with cream d/t fiber and dairy
180
A 58-yr-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? The patient:
is lethargic and difficult to arouse
| worry about extreme electrolyte imbalances- concerned about the difficult to arouse
181
A nurse is caring for a client with constipation whose primary provider has recommended senna for the management of this condition. The nurse should provide which of the following education points?
“Avoid taking the drug on a long-term basis.”
| senna is a stimulant laxative and if taken long term can lead to dependence on the drug
182
After change-of-shift report, which patient should the nurse assess first?
42-yr-old patient who has acute gastritis and ongoing epigastric pain
70-yr-old patient with a hiatal hernia who experiences frequent heartburn
60-yr-old patient with nausea and vomiting who has dry mucosa and lethargy
A.53-yr-old patient who has dumping syndrome after a recent partial gastrectomy
60-yr-old patient with nausea and vomiting who has dry mucosa and lethargy
Electrolyte imbalance- lethargy
183
A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102°F (38.3°C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 89/54 mm Hg. Which prescribed intervention should the nurse implement first?
Bolus a liter of Lactated Ringer’s solution
184
After evacuation of an subdural hematoma, a patient's intracranial pressure (ICP) is being monitored with a ventriculostomy. Which information obtained by the nurse is most important to communicate to the health care provider?
Temperature 101.6 degrees F
185
The nurse has just administered lorazepam to a patient who is in status epilepticus. The patients respiratory rate drops to six per minute. The nurse will prepare to administer:
Flumazenil
186
A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?
Unlicensed assistive personnel enter the patient's room without a mask.
187
The nurse is aware that all of the following electrolyte imbalances can cause a seizure except for:
Hypokalemia
188
The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid?
Head turned to the side
189
A 68-year-old patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?
Check oxygen saturation.
190
The nurse is instructing the client who has been in the hospital with bacterial meningitis and will be going home soon. Which of the following will be of the highest priority?
Take all of the antibiotics as directed until completely gone.
191
The nurse is caring for a patient and the physician has ordered "Seizure Precautions." All of the following will be implemented except for:
Nothing by mouth (NPO).
Suction at the bedside.
Padded bed rails.
Oxygen at the bedside.
NPO
192
A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?
Encourage family members to remain at the bedside.
193
A client is brought to the emergency department in the midst of a persistent tonic-clonic seizure. Lorazepam is administered intravenously. The nurse knows that the purpose of this medication is to:
relax peripheral muscles.
194
The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first
assess the patient for a possible head injury.
195
A client with a history of seizures is scheduled for an arteriogram at 1000 and is to have nothing by mouth before the test. The client is scheduled to receive phenytoin PO at 0900. The nurse should take which of the following actions?
Ask the physician if the drug can be given IV.
196
A patient has increased intracranial pressure (ICP) and a ventriculostomy has been placed after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit?
Check capillary blood glucose level every 6 hours.
197
A client calls the telephone triage nurse to report fever, nausea, chills, and malaise. The nurse instructs the client to come immediately to the emergency room when he relates he also has which of the following
A stiff, sore neck.
198
In providing for the safety of the client during a generalized seizure, the nurse performs which of the following interventions?
Protects the client from injury.
199
A nurse is interviewing a client about past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
Polyps
Explanation:
Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.
200
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following?
Low residue
Explanation:
Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement are prescribed to meet the nutritional needs, reduce inflammation, and control pain and diarrhea.
201
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
Explanation:
A client with appendicitis is at Risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.
202
A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate?
Gently washing the area surrounding the stoma using a facecloth and mild soap
Explanation:
For a client with an ostomy, maintaining skin integrity is a priority. The nurse should gently wash the area surrounding the stoma using a facecloth and mild soap. Scrubbing the area around the stoma can damage the skin and cause bleeding. The faceplate opening should be no more than 1/8-inch to 1/6-inch larger than the stoma. This size protects the skin from exposure to irritating fecal material. The nurse can create an adequate seal and prevent leakage of fecal material from under the faceplate by applying a thin layer of skin barrier and smoothing out wrinkles in the faceplate. Eliminating wrinkles in the faceplate also protects the skin surrounding the stoma from pressure.
203
A client has been diagnosed with cancer in the descending colon. Which symptoms would the nurse expect the client to report? Select all that apply.
narrowing of stools
constipation
Explanation:
Abdominal pain and cramping, narrowing of stools, constipation, abdominal distension, and bright red blood in stools are symptoms associated with cancer in the descending colon. Black, tarry stools and tenesmus are symptoms associated with cancer in the ascending colon.
204
A client tells the nurse, “I am not having normal bowel movements.” When differentiating between what are normal and abnormal bowel habits, what indicators are the most important?
The consistency of stool and comfort when passing stool
Explanation:
In differentiating normal from abnormal, the consistency of stools and the comfort with which a person passes them are more reliable indicators than is the frequency of bowel elimination. People differ greatly in their bowel habits and normal bowel patterns range from three bowel movements per day to three bowel movements per week. It is important for the stool to be soft to pass without pain. The client may not be able to fully evacuate with a bowel movement; it may take time.
205
A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location?
Right lower quadrant
Explanation:
The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.
206
The nurse is performing and documenting the findings of an abdominal assessment. When the nurse hears intestinal rumbling and the client then experiences diarrhea, the nurse documents the presence of which condition?
Borborygmus
Explanation:
Borborygmus is the intestinal rumbling caused by the movement of gas through the intestines that accompanies diarrhea. Tenesmus refers to ineffectual straining at stool. Azotorrhea refers to excess of nitrogenous matter in the feces or urine. Diverticulitis refers to inflammation of a diverticulum from obstruction (by fecal matter) resulting in abscess formation.
207
Which of the following is the most common symptom of a polyp?
Rectal bleeding
Explanation:
The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis.
208
The instructor is teaching a group of students about irritable bowel syndrome (IBS) and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an antidiarrheal agent commonly administered for IBS?
Loperamide
Explanation:
Loperamide is an opiate-related antidiarrheal agent. Lubiprostone is used to treat constipation; it activates chloride channels in the gastrointestinal tract to increase gastrointestinal transit. Dicyclomine, a smooth muscle antispasmodic agent, is used to treat pain accompanying IBS. Peppermint oil may also be taken to ease discomfort.
209
A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult?
"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."
Explanation:
The client stating that he ate roast beef on rye bread indicates the need for a dietary consult because rye bread contains gluten, which must be eliminated from the client's diet. The client stating that he's followed the ordered medication regimen and diet doesn't suggest that the client needs a dietary consult; a treatment regimen consisting of medications to improve symptoms and dietary modification is necessary to treat celiac disease. The client stating that he hasn't traveled outside of the country doesn't suggest that dietary concerns exist. The client saying that he can't have oatmeal shows an understanding of the dietary restrictions necessary with celiac disease.
210
The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation?
Dry skin thoroughly after washing
Explanation:
The nurse should teach the client without peristomal skin irritation to dry the skin thoroughly after washing. Barrier powder, triamcinolone acetonide spray, and nystatin powder are used when the client has peristomal skin irritation and/or fungal infection.
211
A client reports taking a stimulant laxative in order to be able to have a bowel movement daily. What should the nurse inform the client about taking a stimulant laxative?
They can be habit forming and will require increasing doses to be effective.
Explanation:
The nurse should discourage self-treatment with daily or frequent enemas or laxatives. Chronic use of such products causes natural bowel function to be sluggish. In addition, laxatives continuing stimulants can be habit forming, requiring continued use in increasing doses. Although the nurse should encourage the client to have adequate fluid intake, laxative use should not be encouraged. The laxative may interact with other medications the client is taking and may cause a decrease in absorption. A fiber supplement may be taken alone but should not be taken with a stimulant laxative.
212
After teaching a group of students about intestinal obstruction, the instructor determines that the teaching was effective when the students identify which of the following as a cause of a functional obstruction?
Abdominal surgery
Explanation:
In functional obstruction, the intestine can become adynamic from an absence of normal nerve stimulation to intestinal muscle fibers. For example, abdominal surgery can lead to paralytic ileus. Mechanical obstructions result from a narrowing of the bowel lumen with or without a space-occupying mass. A mass may include a tumor, adhesions (fibrous bands that constrict tissue), incarcerated or strangulated hernias, volvulus (kinking of a portion of intestine), intussusception (telescoping of one part of the intestine into an adjacent part), or impacted feces or barium.
213
A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation?
Assist client to increase dietary fiber.
Explanation:
The nurse should assist the client to increase the dietary fiber in food because it helps reduce constipation. Providing an adequate quantity of food is necessary in maintaining sufficient nutrition and in sustaining normal body weight. Obtaining medical, allergy, and food history would provide valuable information, however, it would not help reduce constipation.
214
Celiac disease (celiac sprue) is an example of which category of malabsorption?
Mucosal disorders causing generalized malabsorption
Explanation:
Celiac disease (celiac sprue, gluten-sensitive enteropathy) results from a toxic response to the gliadin component of gluten by the surface epithelium of the intestine; eventually, the mucosal villi of the small intestine become denuded and cannot function. Crohn’s disease (regional enteritis) and radiation enteritis are other examples of mucosal disorders.
215
A patient with IBD would be encouraged to increase fluids, use vitamins and iron supplements, and follow a diet designed to reduce inflammation. Select the meal choice that would be recommended for a low-residue diet.
Broiled chicken with low-fiber pasta
Explanation:
A low-residue, high-protein, and high-calorie diet is recommended to reduce the size and number of stools. Foods to avoid include yogurt, fruit, salami, and peanut butter.
216
Which of the following is considered a bulk-forming laxative?
Metamucil
Explanation:
Metamucil is a bulk-forming laxative. Milk of Magnesia is classified as a saline agent. Mineral oil is a lubricant. Dulcolax is a stimulant.
217
A patient visited a nurse practitioner because he had diarrhea for 2 weeks. He described his stool as large and greasy. The nurse knows that this description is consistent with a diagnosis of:
Intestinal malabsorption.
Explanation:
Watery stools are characteristic of disorders of the small bowel, whereas loose, semisolid stools are associated more often with disorders of the large bowel. Large, greasy stools suggest intestinal malabsorption, and the presence of mucus and pus in the stools suggests inflammatory enteritis or colitis.
218
Vomiting results in which of the following acid–base imbalances?
Metabolic alkalosis
Explanation:
Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.
219
A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client’s constipation?
lack of free water intake
Explanation:
A client who cannot swallow food cannot drink enough water to meet daily needs. Inadequate fluid intake is a common cause of constipation.
220
The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder?
One part of the intestine telescopes into another portion of the intestine.
Explanation:
In intussusception of the bowel, one part of the intestine telescopes into another portion of the intestine. When the bowel twists and turns itself and obstructs the intestinal lumen, this is known as a volvulus. A hernia is when the bowel protrudes through a weakened area in the abdominal wall. An adhesion is a loop of intestine that adheres to an area that is healing slowly after surgery.
221
Medical management of a patient with peritonitis includes fluid, electrolyte, and colloid replacement. The nurse knows to prepare the initial, most appropriate intravenous solution. Which of the following is the correct solution?
0.9% NS
Explanation:
The administration of several liters of an isotonic solution is immediately prescribed. Hypovolemia occurs because massive amounts of fluid and electrolytes move from the intestinal lumen into the peritoneal cavity and deplete the fluid in the vascular space.
222
The nurse is comparing Crohn's disease (regional enteritis) with ulcerative colitis. Which of the following describes Crohn's disease?
Its course is prolonged and variable
Explanation:
The course of Crohn's disease is prolonged and variable whereas ulcerative colitis follows a pattern of exacerbations and remissions. In Crohn's disease, bleeding usually does not occur but tends to be mild when it does occur; fistulas are common, and diarrhea is less severe than it is with ulcerative colitis.
223
A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find?
severe abdominal pain with direct palpation or rebound tenderness
Explanation:
Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (i.e., appendicitis, diverticulitis, ulcerative colitis, a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.
224
A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements?
Antibodies are removed from the plasma.
Explanation:
Plasmapheresis is a technique in which antibodies are removed from plasma and the plasma is returned to the client. The other three choices are appropriate treatments for myasthenia gravis, but are not related to plasmapheresis.
225
The primary arthropod vector in North America that transmits encephalitis is the
mosquito.
Explanation:
Arthropod vectors transmit several types of viruses that cause encephalitis. The primary vector in North America is the mosquito.
226
The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following?
Positive Kernig's sign
Explanation:
A positive Kernig's sign is a common finding in the client with meningitis. When the client is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. A positive Brudzinski's sign is usual with meningitis. The Romberg sign would not be tested in this client. The client will develop lethargy as the illness progresses, not hyper-alertness.
227
A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate?
Treatment with antimicrobial prophylaxis as soon as possible
Explanation:
People in close contact with clients who have meningococcal meningitis should be treated with antimicrobial chemoprophylaxis, ideally within 24 hours after exposure.``
228
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?
Headache and nuchal rigidity
Explanation:
Headache and fever are the initial symptoms of meningitis. Nuchal rigidity can be an early sign. Photophobia is also a well-recognized sign in meningitis. Ptosis and diplopia are usually seen with myasthenia gravis. Hyporeflexia in the legs is seen with Guillain-Barre syndrome.
229
A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?
Positive Brudzinski's sign
Explanation:
A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced. A positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.
230
While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?
Facial pain in the areas of the fifth cranial nerve
Explanation:
Tic douloureux (trigeminal neuralgia) is manifested by pain in the areas of the fifth (trigeminal) cranial nerve. Ptosis and diplopia are associated with myasthenia gravis. Hyporeflexia and weakness of the lower extremities are associated with Guillain-Barre syndrome. Fatigue and depression are associated with multiple sclerosis.
231
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?
Edrophonium (Tensilon)
Explanation:
Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma.
232
The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.
Explanation:
Thirty seconds after injection, facial muscle weakness and ptosis should resolve for about 5 minutes (Hickey, 2009). Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis.
233
A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?
Initiate isolation precautions.
Explanation:
The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done after applying isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.
234
The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following?
Bacteria
Explanation:
Septic meningitis is caused by bacteria. In aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or human immunodeficiency virus.
235
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions?
Renal
Explanation:
Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.
236
The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily?
Respiratory
Explanation:
Because of its possible rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency. After baseline values are identified, assessment of changes in muscle strength and respiratory function alert the team to the physical and respiratory needs of the client. The other three choices may become problem areas later, but respiratory issues are always a priority.
237
Myasthenia gravis occurs when antibodies attack which receptor sites?
Acetylcholine
Explanation:
In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and gamma-aminobutyric acid are not receptor sites that are attacked in myasthenia gravis.
238
A neurologic deficit is best defined as a deficit of the:
central and peripheral nervous systems with decreased, impaired, or absent functioning.
Explanation:
A client with a neurologic deficit may have decreased, impaired, or absent functioning of the central and peripheral systems.
239
The initial symptoms of variant Creutzfeldt-Jakob disease (vCJD) include
sensory disturbance, limb pain, and behavioral changes.
Explanation:
Sensory disturbance, limb pain, and behavioral changes are the initial symptoms of vCJD. Memory and cognitive impairment occur late in the course of vCJD. The other symptoms listed may happen in the later stages of vCJD.
240
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
"The paralysis caused by this disease is temporary."
Explanation:
The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.
241
Which drug should be available to counteract the effect of edrophonium chloride?
Atropine
Explanation:
Atropine should be available to control the side effects of edrophonium chloride. Prednisone, azathioprine, and pyridostigmine bromide are not used to counteract these effects.
242
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?
Alternatively patch one eye every 2 hours.
Explanation:
Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.
243
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?
Tensilon test
Explanation:
Edrophonium chloride (Tensilon) is an acetylcholinesterase inhibitor that stops the breakdown of acetylcholine. The drug is used because it has a rapid onset of 30 seconds and a short duration of 5 minutes. Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis. The presence of acetylcholine receptor antibodies is identified in serum. Repetitive nerve stimulation demonstrates a decrease in successive action potentials. The thymus gland may be enlarged in MG, and a T scan of the mediastinum is performed to detect thymoma or hyperplasia of the thymus.
244
A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, “You don’t know what you are doing!” What is the best reaction by the nurse?
Accept the patient's behavior and do not take it personally.
Explanation:
Anger is a defense or response to loss; the nurse should consider that the client is using displacement to deal with emotional pain. Having another nurse care for the patient might send a message to the client that may precipitate feelings of guilt or imply to the client that the nurse no longer wants to provide care. Discontinuing the bath abandons the client and would not encourage expression of feelings. Explaining that the client is getting good care is a defensive response that focuses on the nurse rather than the client.
245
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in an air-conditioned room.
Explanation:
Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.
246
Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis?
Controlling seizures and increased intracranial pressure
Explanation:
There is no specific medication for arboviral encephalitis; therefore symptom management is key. Medical management is aimed at controlling seizures and increased intracranial pressure.
247
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?
Diplopia and ptosis
Explanation:
The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis.
248
The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?
“I was brushing my teeth.”
Explanation:
Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of sudden pain in the area innervated by any of the three branches of the nerve. Paroxysms can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking.
249
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?
"Have you experienced any viral infections in the last month?"
Explanation:
An antecedent event (most often a viral infection) precipitates clinical presentation. The antecedent event usually occurs about 2 weeks before the symptoms begin. Ptosis is a common symptom associated with myasthenia gravis. Urination and development of allergies are not associated with Guillain-Barre.
250
A client is diagnosed with a brain abscess. Which medication will the nurse anticipate providing to the client? Select all that apply.
Correct response:
Metronidazole
Dexamethasone
Lacosamide
Explanation:
A brain abscess is a collection of infectious material within the tissue of the brain. Bacteria are the most common causative organisms. The most common predisposing conditions for abscesses among adults who are immunocompetent are otitis media and rhinosinusitis. Treatment is aimed at controlling increased intracranial pressure (ICP), draining the abscess, and providing antimicrobial therapy directed at the abscess and the main source of infection. It is important for antibiotics such as metronidazole to be started as soon as possible. Corticosteroids such as dexamethasone are used to reduce the cerebral edema caused by inflammation. Anticonvulsants such as lacosamide may be prescribed to prevent or treat seizures. Anticoagulants such as apixaban and opioid analgesics such as hydrocodone are not medications used to treat a brain abscess.
251
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds
Explanation:
An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance. A decrease in pulse rate is not indicative of airway obstruction. An increase of pulse rate with slight elevation of respirations (16 breaths/minute) is not significant for suctioning unless findings suggest otherwise.
252
A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide?
“You must avoid stress and extreme fatigue, because these can trigger a relapse.”
Explanation:
Stress, fatigue, and temperature extremes can trigger relapses of MS. The client should be taught to practice a healthy lifestyle, including good nutrition, adequate sleep, and management of stress. Clients taking MS medications should take them on a consistent and strict schedule to produce the desired effect of fewer relapses and to prevent sclerotic plaque from forming on the brain and spinal cord. RRMS is characterized by states of remission and relapses. A steady decline in function is consistent with primary progressive MS. RRMS is the most common type, and many treatments are available.
253
The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following?
Approximately 60% to 75% of clients recover completely.
Explanation:
Results of studies on Guillain-Barre syndrome indicate that 60% to 75% of clients recover completely.
254
The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?
Facial distortion and pain
Explanation:
Bell's palsy is manifested by facial distortion, increased tearing, and painful sensations in the face, behind the ear, and in the eye. Ptosis and diplopia are associated with myasthenia gravis. Hyporeflexia and weakness of the lower extremities are associated with Guillain-Barre syndrome. Fatigue and depression are associated with multiple sclerosis.
255
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?
Administer atropine to control the side effects of edrophonium.
Explanation:
Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.
256
Which is the most common cause of acute encephalitis in the United States?
Herpes simplex virus (HSV)
Explanation:
HSV-1 ( herpes simplex virus) is the most common cause of acute encephalitis in the United States. Fungal infections of the central nervous system occur rarely in healthy people. The Western equine encephalitis virus is one of four types of arboviral encephalitis that occur in North America is one of several fungi that may cause fungal encephalitis. Lyme disease leads to flu like symptoms and starts as a local infection which can systematically spread causing organ issues, however the incidence is rate, HIV leads to autoimmune disorders.
257
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest?
Take small meals of soft consistency
Explanation:
To help a client with trigeminal neuralgia, who suffers pain in the jaws meet his or her nutritional needs, the nurse should offer small meals of soft consistency. Foods may be pureed to minimize jaw movements when eating. There is no need for the client to increase the intake of fruits and raw vegetables, calcium, or proteins during trigeminal neuralgia. The nurse should avoid offering meat and fish in the diet because they require excessive chewing by the client.
258
The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?
“I will stretch daily as directed by the physical therapist.”
Explanation:
A stretching routine should be established. Stretching can help prevent contractures and muscle spasticity. Hot baths are discouraged because of the risk of injury. Clients have sensory loss that may contribute to the risk of burns. In addition, hot temperatures may cause an increase in symptoms. Warm packs should be encouraged to provide relief. Progressive weight-bearing exercises are effective in managing muscle spasms. Clients should not hurry through the exercise activity because it may increase muscle spasticity.
259
Which of the following is considered a central nervous system (CNS) disorder?
Multiple sclerosis
Explanation:
Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.
260
Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
Speeds nerve impulse transmission
Explanation:
Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger.
261
The purpose of withholding food and fluid before surgery is to prevent ________________.
aspiration
262
An obese patient tends to have shallow respirations when supine, increasing the risk of hypoventilation and postoperative _____________ complications.
pulmonary
263
T/F: Surgery classification based on the degree of urgency is considered emergent if it is scheduled within 24 to 30 hours (e.g., acute gallbladder infection).
FALSE-
When a patient's condition is life threatening, surgery is considered emergent. Emergency surgeries must be performed immediately, even when the patient is unconscious and cannot give consent
264
T/F: Aspirin, a common over-the-counter (OTC) medication that inhibits platelet aggregation, should be prudently discontinued 7 to 10 days before surgery or the patient may be at increased risk for bleeding.
TRUE
265
Scrub nurses and circulating nurses care for patients during the ____________ phase of perioperative nursing.
intraoperative
266
T/F: Any nutritional deficiency prior to surgery should be corrected before surgery to provide adequate protein for tissue repair and collagen deposition.
TRUE
267
The patient with diabetes is at risk for _______________, either during anesthesia or postoperatively, from inadequate carbohydrates or excessive administration of insulin.
hypoglycemia
268
Dehydration, hypovolemia, and __________________ imbalances can lead to significant problems in patients with comorbid medical conditions or in older adults.
electrolyte
269
T/F: Patients who smoke are urged to stop 1 to 3 weeks before surgery to significantly reduce pulmonary and wound healing complications.
FALSE- online says at least 8 weeks but maybe its because in NCLEX world the answer is to never smoke
270
T/F: It is the doctor's responsibility to provide appropriate information concerning surgery and obtain the written surgical consent.
TRUE
271
A ____________ is the most common type of intracerebral brain neoplasm.
glioma
272
The pharmacologic agent ________________, which is converted to dopamine in the basal ganglia, is the most effective agent, and the mainstay of treatment, for Parkinson disease.
Levodopa
273
T/F: Low back pain, accompanied by muscle spasm with radicular pain and radiation of the pain into one hip and down into the leg, is a symptom of a herniated lumbar disk that is referred to as sciatica.
TRUE
274
T/F: Intramedullary lesions are tumors within the spinal cord.
True
275
Each child of a parent with Huntington disease has a ______ risk of inheriting the disorder.
50% or 0.5
276
T/F: Thalamotomy and pallidotomy are successful ablative procedures used to relieve symptoms of Parkinson disease.
FALSE- although they are both surgical procedures for Parkinson's, they are not successful in curing the disease
277
T/F: Parkinson disease is associated with decreased levels of dopamine resulting from degeneration of these storage cells in the substantia nigra in the basal ganglia region of the brain.
True
278
T/F: The highest incidence of brain tumors in adults occurs in the fifth to seventh decades of life.
TRUE
279
One of the most common features of _________ disease is bradykinesia.
Parkinsons
280
An ____________ is the most helpful diagnostic tool for detecting brain tumors
MRI
281
A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?
Evisceration
Explanation:
Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.
282
Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?
Vital signs within normal limits; absence of chills and cough
Explanation:
Pneumonia is characterized by chills, fever, tachypnea, tachycardia, and sometimes cough.
283
A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?
Wound dehiscence
Explanation:
Risk factors for wound dehiscence include advanced age over 65 years, chronic disease such as diabetes, hypertension, obesity, history of radiation or chemotherapy, malnutrition, particularly insufficient protein and vitamin C, and hypoalbuminemia. This client is not at increased risk for hypotension, contractures, or phlebitis.
284
A client recovering from surgery is at risk for respiratory complications. The nurse knows which action(s) could improve a client’s respiratory status? Select all that apply.
Turn and reposition the client.
Instruct the client to yawn frequently.
Coach the client to take deep breaths and cough.
Increase the rate of the intravenous fluid infusion.
Remind the client to use the incentive spirometer every 2 hours.
To clear secretions and prevent pneumonia in the client recovering from surgery, the nurse will turn or encourage the client to turn frequently. To encourage lung expansion, the client is instructed to yawn frequently. Deep breathing and coughing is another intervention to improve respiratory functioning in addition to using the incentive spirometer at least every 2 hours. A health care provider’s prescription is required to change the flow rate of intravenous fluids.``
285
What is the highest priority nursing intervention for a client in the immediate postoperative phase?
Maintaining a patent airway
Explanation:
All interventions listed are correct. The highest priority intervention, however, is maintaining a patent airway. Without a patent airway, the other interventions—monitoring vital signs, assessing urinary output, and assessing for hemorrhage—become secondary to the possibility of a lack of oxygen.
286
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?
Reinforcing the dressing or applying pressure if bleeding is frank
Explanation:
The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.
287
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
First intention
Explanation:
When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.
288
A term used to describe a partial or complete separation of wound edges is
dehiscence.
Explanation:
Dehiscence is the partial or complete separation of wound edges. Evisceration occurs when organs protrude through the surgical incision. Erythema refers to redness of the skin. Hemorrhage is excessive bleeding.
289
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?
Ineffective thermoregulation
Explanation:
Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.
290
The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼–inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists?
Dehiscence
Explanation:
Dehiscence is a disruption of the incision.
291
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?
Pneumonia
Explanation:
Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult.
292
The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?
“I can resume my usual activities as soon as I get home.”
Explanation:
By time of discharge, clients should be able to verbalize clinical manifestations of complications, activity and diet restrictions, and specifics regarding follow-up appointments. The client with abdominal incision will need to avoid lifting and driving in the initial discharge period.
293
When should the nurse encourage the postoperative patient to get out of bed?
As soon as it is indicated
Explanation:
Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first.
294
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?
<30 mL
Explanation:
If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported.
295
The primary objective in the immediate postoperative period is
maintaining pulmonary ventilation.
Explanation:
The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period.
296
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?
Correct response:
The Hemovac drain isn't compressed; instead it's fully expanded.
The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.
297
The nurse is preparing discharge instructions to a client who has undergone minor same-day surgery. Which client statement indicates that teaching has been effective?
“I am not permitted to drive myself home after surgery."
Explanation:
There are specific educational points that the nurse needs to provide to the client before discharging after a same-day procedure. After teaching, the client should be able to describe activities that can or cannot be performed, such as limited driving for 2 days. Rather than self-teaching at home, the discharge instructions will educate the client how to identify interventions and strategies for adaptive equipment. The client should be instructed to call the health care provider for a follow-up postsurgical appointment. The client should be able to name the procedure that was performed and not just give a vague statement of something being done in the abdomen.
298
The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?
7
Explanation:
Many hospitals use a scoring system (e.g., Aldrete score) to determine the patient’s general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient’s physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the patient’s condition in the PACU. The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 7 and 10 before discharge from the PACU.
299
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
auscultate bowel sounds.
Explanation:
If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.
300
The nurse teaches the client that corticosteroids will be used to treat his brain tumor to
reduce cerebral edema.
Explanation:
Corticosteroids may be used before and after treatment to reduce cerebral edema and to promote a smoother, more rapid recovery. Corticosteroids do not prevent extension of the tumor or facilitate regeneration of neurons. Stereotactic procedures identify the precise location of the tumor.
301
A client with spinal cord compression from a tumor must undergo diagnostic testing. Which of the following is the most likely procedure for this client?
Magnetic resonance imaging
Explanation:
Magnetic resonance imaging is the most commonly used diagnostic procedure. It is the most sensitive diagnostic tool that is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases.
302
Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter?
Dopamine
Explanation:
The impaired balance and uncontrolled tremors of Parkinson's disease have been linked with low levels of dopamine. The other neurotransmitters have not been implicated in Parkinson's disease in this manner.
303
The nurse explains to the client with projectile vomiting and severe headache that a medication is being prescribed to reduced edema surrounding the brain and lessen these symptoms. What medication is the nurse preparing to administer?
Mannitol
Explanation:
Mannitol is an osmotic diuretic that is administered to decrease the fluid content of the brain, which leads to a decrease in intracranial pressure. Temozolomide is a chemotherapeutic agent which is commonly used to stop or slow cell growth in certain types of brain tumors. Bevacizumab and everolimus are immunotherapy agents that reduce the vascularization of tumors, thereby inhibiting tumor growth.
304
A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response?
“Treatment aims at keeping you independent as long as possible.”
Explanation:
Treatment aims at prolonging independence. Treatment does matter, it is not palliative, and it is not aimed at keeping you emotionally healthy.
305
A 55-year-old female client presents at the walk-in clinic complaining of feeling like a mask is on her face. While doing the initial assessment, the nurse notes the demonstration of a pill-rolling movement in the right hand and a stooped posture. Physical examination shows bradykinesia and a shuffling gait. What would the nurse suspect is the causative factor for these symptoms?
Parkinson's disease
Explanation:
Early signs include stiffness, referred to as rigidity, and tremors of one or both hands, described as pill-rolling (a rhythmic motion of the thumb against the fingers). The hand tremor is obvious at rest and typically decreases when movement is voluntary, such as picking up an object. Bradykinesia, slowness in performing spontaneous movements, develops. Clients have a masklike expression, stooped posture, hypophonia (low volume of speech), and difficulty swallowing saliva. Weight loss occurs. A shuffling gait is apparent, and the client has difficulty turning or redirecting forward motion. Arms are rigid while walking. These symptoms are not indicative of MS, Myasthenia gravis, or Huntington's.
306
The nurse is providing end-of-life care to a client who was diagnosed with glioblastoma multiforme (GBM) 8 months ago. Despite a calm interaction with the client 1 hour ago, the client is now angry and yells, "Get out of my room and don't touch me anymore. I don't need your help!" How should the nurse respond?
"I can tell now is not the right time for me to come in and check on you. Please let me know when it is a better time for me to come back."
Explanation:
Personality changes, mood swings and irritability can be common manifestations of both growth of the brain tumor and also the process of grief and loss, such as in the case of the client who is receiving end-of-life care. The client's anger and yelling at the nurse is indicative of ineffective coping and warrants the nurse to take a therapeutic approach when responding to the anger. Acknowledging that the client is not ready to receive care at the moment and asking the client to contact the nurse when he or she is ready enables to client to maintain control and promotes self-esteem. Telling the client to speak to the nurse's supervisor does not promote a strong nurse-patient relationship and is not a supportive way to manage end-of-life care. Telling the client that he or she is not permitted to speak to the nurse "that way" may increase the client's anger and puts limits on the client's sense of control. This response does not promote an effective nurse-patient relationship. The nurse must use extra caution when responding to a client who is experiencing emotional swings when faced with death and dying. By stating, "I can see you no longer want me as your nurse," the nurse is making an assumption that the client does not want him or her as the nurse any longer. By making this statement, the nurse is limiting opportunities for the client to verbalize feelings and emotions related to stress, grief and loss.
307
What is the only known risk factor for brain tumors?
Ionizing radiation
Explanation:
Ionizing radiation is the only known risk factor for brain tumors. Head trauma, use of hair dyes, and the use of cellular phones are possible causes that have been investigated.
308
A client has undergone surgery for a spinal cord tumor that was located in the cervical area. The nurse would be especially alert for which of the following?
Respiratory dysfunction
Explanation:
When a spinal tumor is located in the cervical area, respiratory compromise may occur from postoperative edema. Hemorrhage would be a concern with any surgery. Bowel incontinence and skin breakdown are possible but not specific to cervical spinal tumors.
309
Which client should the nurse assess for degenerative neurologic symptoms?
The client with Huntington disease.
Explanation:
Huntington disease is a chronic, progressive, degenerative neurologic hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia. Paget disease is a musculoskeletal disorder, characterized by localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae. Osteomyelitis is an infection of the bone. Malignant glioma is the most common type of brain tumor.
310
Through which route are general anesthetics primarily eliminated?
Lungs- general anesthetics (halothane) are inhaled most often to they are eliminated through the lungs
311
Maintaining an aseptic environment in the OR is essential to client safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?
1 foot (30 cm)
312
Is the following statement true or false?
The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of laryngospasm.
FALSE- b/c don't need to prevent laryngospasma, that is rare after surgery
313
Which medication classification must be assessed during the preoperative period because it can cause an electrolyte imbalance during surgery?
Diuretics
314
A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action?
Quickly attempt to determine the cause of hemorrhage.
315
The nurse is caring for a client after abdominal surgery in the PACU. The client's blood pressure has increased and the client is restless. The client's oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?
Pain
316
The perioperative nurse is preparing to discharge a female client home from day surgery performed under general anesthetic. What instruction should the nurse give the client prior to the client leaving the hospital?
The client should not drive herself home
317
The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, “I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest.” What rationale for these instructions should the nurse provide?
To promote optimal lung expansion
318
A client is scheduled for a bowel resection in the morning and the client's orders include a cleansing enema tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect?
Preventing potential contamination of the peritoneum
319
The nurse is caring for a client on the medical–surgical unit postoperative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indicative of infection?
Red, warm, tender incision
320
A patient is prescribed to take Carbidopa/Levodopa. As the nurse you know that which statement is incorrect about this medication:
It can take up to 3 weeks for the patient to notice a decrease in signs and symptoms when beginning treatment with this medication.
Body fluids can turn a dark color and stain clothes.
This medication is most commonly prescribed with a vitamin B6 supplement.
Carbidopa helps to prevent Levodopa from being broken down in the blood before it enters the brain. Hence, levodopa is able to enter the brain.
This medication is most commonly prescribed with a vitamin B6 supplement.
321
Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles?
Imbalanced nutrition: less than body requirements
322
The wife of a client diagnosed with a brain tumor tells the nurse "I don't know how I will make it if something happens to my husband. I love him so much." Which statement is most appropriate for the nurse to say?
"What do you mean, that you don't know how you will make it if something happens?"
323
As the home health nurse you are helping a patient with Parkinson’s Disease get dressed. What item gathered by the patient to wear should NOT be worn?
Rubber sole shoes
324
A physician orders a patient to take Benztropine. The patient has never taken this medication before and is due to take the first dose at 1000. What statement by the patient requires you to hold the dose and notify the physician?
“I forgot to tell the doctor I take eye drops for my glaucoma.”
325
When caring for a patient following a lumbar laminectomy, the nurse should
place a pillow between the patient's legs before turning to the side.
326
A patient with Parkinson’s Disease has slow movements that affects their swallowing, facial expressions, and ability to coordinate movements. As the nurse you will document the patient has:
Bradykinesia
327
Which action will the nurse take first when a patient is seen in the outpatient clinic with neck pain?
Ask about numbness or tingling of the hands and arms.
328
The nurse is changing an abdominal dressing for a client. To prevent back injury while leaning over the client, the nurse should do which of the following?
Raise the bed to a comfortable position.
329
A patient with Parkinson Disease is experiencing weight loss due to difficulty chewing and swallowing. Which meal option below is the best for this patient?
Scrambled eggs with a side of cottage cheese
330
The nurse is aware that the pituitary gland stores hormones secreted by the hypothalamus for later use. All of the following hormones play a role in the regulation of water conservation except for
Oxytocin
Antidiuretic Hormone (ADH)
Adrenocorticotropic Hormone (ACTH)
Vasopressin
Adrenocorticotropic Hormone (ACTH)
331
Which of the following is a characteristic of all hormones?
Hormones enter a cell to alter the cell's metabolism or gene structure.
Hormones circulate in the blood bound to plasma proteins.
Hormones influence cellular activity of specific target tissues.
Hormones accelerate the metabolic processes of all body cells.
Hormones influence cellular activity of specific target tissues.
332
The nurse knows that hormone balance occurs through a negative-feedback system. Which of the following occurs as a result of this system?
Target organ effects inhibit further hormone release.
333
During the nurse's physical examination of a 25-year old female, the patient's thyroid gland feels enlarged. The most appropriate action by the nurse is to:
auscultate both lobes with a stethoscope.
334
Thyroid hormones play an important role in many bodily functions. Which of the following is NOT one of the areas in which thyroid hormone (TH) plays an important role?
Normal skeletal and nervous system development and maturation
Regulation of tissue growth and development
Blood pressure maintenance.
Helping the body avoid dehydration and water overload.
Helping the body avoid dehydration and water overload.
335
Parathyroid hormone (PTH) results in what chemical changes in the body?
PTH results in an an increase calcium and decrease in phosphate.
336
The patient is experiencing tachycardia, increased blood pressure, and anxiety. Which endocrine hormones are likely responsible for the symptoms?
Epinephrine and Norepinephrine
337
Which statement by a 50-yr-old female patient indicates to the nurse that further assessment of thyroid function may be necessary?
"I feel a lump in my throat when I swallow."
338
The nurse knows that endocrine disorders often go unrecognized in the older adult due to which of the following statements?
Symptoms are often attributed to aging.
339
The nurse is developing a care plan for a patient who has just undergone a near-total thyroidectomy. What information must be included in the plan?
The patient should undergo measures to prevent vocal cord edema.
