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1

A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which
action should the nurse take when providing education about newly prescribed medications to this client?
a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the clients right side and speak into the right ear. d. Allow the client to use a white board to ask questions.

ANS: C
The temporal lobe contains the auditory center for sound interpretation. The clients hearing will be impaired in
the left ear. The nurse should sit on the clients right side and speak into the right ear. The other interventions do
not address the clients left temporal lobe damage.

2

A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which
intervention should the nurse include in this clients plan of care?
a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the clients legs. d. Assess the clients feet for wounds each shift.

ANS: B
Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing
the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The
other interventions do not address the clients problem.

3

A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse
include in this clients teaching?
a. Place soft rugs in your bathroom to decrease pain in your feet. b. Bathe in warm water to increase your circulation. c. Look at the placement of your feet when walking. d. Walk barefoot to decrease pressure ulcers from your shoes.

ANS: C
Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when
walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when
walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for
thermal injury. The client should wear sturdy shoes for ambulation.

4

A nurse assesses a clients recent memory. Which client statement confirms that the clients remote memory
is intact?
a. A young girl wrapped in a shroud fell asleep on a bed of clouds.
b. I was born on April 3, 1967, in Johnstown Community Hospital. c. Apple, chair, and pencil are the words you just stated. d. I ate oatmeal with wheat toast and orange juice for breakfast.

`ANS: D
Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the
clients recent memory. The clients ability to make up a rhyme tests not memory, but rather a higher level of
cognition. Asking clients about certain facts from the past that can be verified assesses remote or long-term
memory. Asking the client to repeat words assesses the clients immediate memory.

5

A nurse assesses a client who demonstrates a positive Rombergs sign with eyes closed but not with eyes
open. Which condition does the nurse associate with this finding?
a. Difficulty with proprioception
b. Peripheral motor disorder
c. Impaired cerebellar function
d. Positive pronator drift

ANS: A
The client who sways with eyes closed (positive Rombergs sign) but not with eyes open most likely has a
disorder of proprioception and uses vision to compensate for it. The other options do not describe a positive
Rombergs sign

6

A nurse asks a client to take deep breaths during an electroencephalography. The client asks, Why are you
asking me to do this? How should the nurse respond?
a. Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain. b. Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform. c. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity. d. Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures.

ANS: C
Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure
activity. The client is asked to breathe deeply 20 to 30 times for 3 minutes. The other responses are not
accurate.

7

A nurse assesses a client recovering from a cerebral angiography via the clients right femoral artery. Which
assessment should the nurse complete?
a. Palpate bilateral lower extremity pulses. b. Obtain orthostatic blood pressure readings. c. Perform a funduscopic examination. d. Assess the gag reflex prior to eating.

ANS: A
Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The
extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic blood pressure readings cannot be performed. The
funduscopic examination would not be affected by cerebral angiography. The client is given analgesics but not
conscious sedation; therefore, the clients gag reflex would not be compromised.

8

A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test?
a. Have you had a recent blood transfusion?
b. Do you have allergies to iodine or shellfish?
c. Are you taking any cardiac medications?
d. Do you currently use oral contraceptives?

ANS: B
Allergies to iodine and/or shellfish need to be explored because the client may have a similar reaction to the
dye used in the procedure. In some cases, the client may need to be medicated with antihistamines or steroids
before the test is given. A recent blood transfusion or current use of cardiac medications or oral contraceptives
would not affect the angiography.

9

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed
tomography scan of the head with contrast medium. Which priority intervention should the nurse implement?
a. Educate the client about strict bedrest after the procedure. b. Place an indwelling urinary catheter to closely monitor output. c. Obtain a prescription for intravenous fluids. d. Contact the provider to cancel the procedure.

ANS: C
If a contrast medium is used, intravenous fluid may be given to promote excretion of the contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid replacement. The client will not
require bedrest. Although urinary output should be monitored closely, there is no need for an indwelling
urinary catheter. There is no need to cancel the procedure as long as actions are taken to protect the kidneys.

10

A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging
(MRI). Which condition should alert the nurse to contact the provider and cancel the procedure?
a. Creatine phosphokinase (CPK) of 100 IU/L
b. Atrioventricular graft
c. Blood urea nitrogen (BUN) of 50 mg/dL
d. Internal insulin pump

ANS: D
Metal devices such as internal pumps, pacemakers, and prostheses interfere with the accuracy of the image and
can become displaced by the magnetic force generated by an MRI procedure. An atrioventricular graft does not
contain any metal. CPK and BUN levels have no impact on an MRI procedure.

11

A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which
statement should the nurse include in this clients teaching?
a. Avoid caffeine-containing substances for 12 hours before the test. b. Drink at least 3 liters of fluid during the first 24 hours after the test. c. Do not take your cardiac medication the morning of the test. d. Remove your dentures and any metal before the test begins

ANS: A
Caffeine-containing liquids and foods are central nervous system stimulants and may alter the test results. No
contrast is used; therefore, the client does not need to increase fluid intake. The client should take cardiac
medications as prescribed. Metal does not have to be removed; this is done for magnetic resonance imaging.

12

A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, I am
worried I will not be able to care for my young children. How should the nurse respond?
a. Caring for your children is a priority. You may not want to ask for help, but you have to. b. Our community has resources that may help you with some household tasks so you have energy to care for
your children. c. You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?
d. Give me more information about what worries you, so we can see if we can do something to make
adjustments.

ANS: D
Investigate specific concerns about situational or role changes before providing additional information. The
nurse should not tell the client what is or is not a priority for him or her. Although community resources may
be available, they may not be appropriate for the client. Consulting a psychologist would not be appropriate
without obtaining further information from the client related to current concerns.

13

A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this clients plan of care?
a. Provide a call button that requires only minimal pressure to activate. b. Write the date on the clients white board to promote orientation. c. Ensure that the path to the bathroom is free from equipment. d. Encourage the client to season food to stimulate nutritional intake.

ANS: C
Dementia and confusion are not common phenomena in older adults. However, physical impairment related to
illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility
(and ensure safety). Providing a call button, providing the date, and seasoning food do not address the clients
impaired sensory perception.

14

After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the
clients understanding. Which client statement indicates a correct understanding of the teaching?
a. I must increase my fluids because of the dye used for the MRI. b. My urine will be radioactive so I should not share a bathroom. c. I can return to my usual activities immediately after the MRI. d. My gag reflex will be tested before I can eat or drink anything.

ANS: C
No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is
complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not
needed and the clients urine would not be radioactive. The procedure does not impact the clients gag reflex.

15

A nurse performs an assessment of pain discrimination on an older adult client. The client correctly
identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should
the nurse take next?
a. Touch the pin on the same area of the left hand. b. Contact the provider with the assessment results. c. Ask the client about current medications. d. Continue the assessment on the clients feet.

ANS: A
If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse should
continue the assessment on the left hand. This is a normal finding and does not need to be reported to the
provider, but instead documented in the clients chart. Medications do not need to be assessed in response to
this finding. The nurse should assess the left hand prior to assessing the feet.

16

A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include
in this clients discharge teaching?
a. Connect a light to flash when your door bell rings. b. Label your faucet knobs with hot and cold signs. c. Ask a friend to drive you to your follow-up appointments. d. Use a natural gas detector with an audible alarm.

A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include
in this clients discharge teaching?
a. Connect a light to flash when your door bell rings. b. Label your faucet knobs with hot and cold signs. c. Ask a friend to drive you to your follow-up appointments. d. Use a natural gas detector with an audible alarm.

17

. A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement should the nurse
include when delegating care for a client with cranial nerve II impairment?
a. Tell the client where food items are on the breakfast tray. b. Place the client in a high-Fowlers position for all meals. c. Make sure the clients food is visually appetizing. d. Assist the client by placing the fork in the left

ANS: A
Cranial nerve II, the optic nerve, provides central and peripheral vision. A client who has cranial nerve II
impairment will not be able to see, so the UAP should tell the client where different food items are on the meal
tray. The other options are not appropriate for a client with cranial nerve II impairment.

18

A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to
contact the health care provider?
a. Shingles on the clients back
b. Client is claustrophobic
c. Absence of intravenous access
d. Paroxysmal nocturnal dyspnea

ANS: A
An LP should not be performed if the client has a skin infection at or near the puncture site because of the risk
of infection. A nurse would want to notify the health care provider if shingles were identified on the clients
back. If a client has shortness of breath when lying flat, the LP can be adapted to meet the clients needs. Claustrophobia, absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP
can be performed.

19

A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication of this
procedure should alert the nurse to urgently contact the health care provider?
a. Weak pedal pulses
b. Nausea and vomiting
c. Increased thirst
d. Hives on the chest

ANS: B
The nurse should immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased
intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP.

20

A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT)
with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care
with this client?
a. You may return to your previous activity level immediately. b. You are radioactive and must use a private bathroom. c. Frequent assessments of the injection site will be completed. d. We will be monitoring your renal functions closely.

ANS: A
The client may return to his or her previous activity level immediately. Radioisotopes will be eliminated in the
urine after SPECT, but no monitoring or special precautions are required. The injection site will not need to be
assessed after the procedure is complete.

21

A nurse assesses a client and notes the clients position as indicated in the illustration below:
How should the nurse document this finding?
a. Decorticate posturing
b. Decerebrate posturing
c. Atypical hyperreflexia
d. Spinal cord degeneration

ANS: A
The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the clients condition has deteriorated. The physician, the charge
nurse, and other health care team members should be notified immediately of this change in status. Decerebrate
posturing consists of external rotation and extension of the extremities. Hyperreflexes present as increased
reflex responses. Spinal cord degeneration presents frequently with pain and discomfort.

22

A nurse assesses the left plantar reflexes of an adult client and notes the response shown in the photograph
below:
Which action should the nurse take next?
a. Contact the provider with this abnormal finding. b. Assess bilateral legs for temperature and edema. c. Ask the client about pain in the lower leg and calf. d. Document the finding and continue the assessment.

ANS: A
This finding indicates Babinskis sign. In clients older than 2 years of age, Babinskis sign is considered
abnormal and indicates central nervous system disease. The nurse should notify the health care provider and
other members of the health care team because further investigation is warranted. This finding does not relate
to perfusion of the leg or to pain. This is an abnormal assessment finding and should be addressed
immediately.

23

A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How should the nurse document this clients
assessment using the Glasgow Coma Scale shown below?
a. 8
b. 10
c. 12
d. 14

ANS: C
The client opens his eyes to speech (Eye opening: To sound = 3), mumbles in response to questions (Verbal
response: Inappropriate words = 3), and follows simple commands (Motor response: Obeys commands = 6). Therefore, the clients Glasgow Coma Scale score is: 3 + 3 + 6 = 12.

24

A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse
expect to find? (Select all that apply.)
a. Loss of smell
b. Impaired swallowing
c. Visual changes
d. Inability to shrug shoulders
e. Loss of gag reflex

ANS: B, D, E
Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the
medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes
impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not
associated with damage to the medulla.

25

An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball. For
which clinical manifestations that are related to a temporal lobe injury should the nurse assess? (Select all that
apply.)
a. Memory loss
b. Personality changes
c. Difficulty with sound interpretation
d. Speech difficulties
e. Impaired taste

ANS: A, C, D
Wernickes area (language area) is located in the temporal lobe and enables the processing of words into
coherent thought as well as the understanding of written or spoken words. The temporal lobe also is
responsible for the auditory centers interpretation of sound and complicated memory patterns. Personality
changes are related to frontal lobe injury. Impaired taste is associated with injury to the parietal lobe.

26

After administering a medication that stimulates the sympathetic division of the autonomic nervous system,
the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply.)
a. Decreased respiratory rate
b. Increased heart rate
c. Decreased level of consciousness
d. Increased force of contraction
e. Decreased blood pressure

ANS: B, D
Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart
rate and the force of contraction. A medication that stimulates the sympathetic nervous system would also
increase the clients respiratory rate, blood pressure, and level of consciousness.

27

A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the
nurse to urgently communicate with the health care provider? (Select all that apply.)
a. Glasgow Coma Scale score of 8
b. Decerebrate posturing
c. Reactive pupils
d. Uninhibited speech
e. Diminished cognition

ANS: A, B, E
The nurse should urgently communicate changes in a clients neurologic status, including a decrease in the
Glasgow Coma Scale score, abnormal flexion or extension, changes in cognition or speech, and pinpointed, dilated, and nonreactive pupils

28

A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based
contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)
a. Ensure that an informed consent is present. b. Ask the client about any allergies. c. Evaluate the clients renal function. d. Auscultate bilateral breath sounds. e. Assess hematocrit and hemoglobin lev

ANS: A, B, C
A client who is scheduled to receive iodine-based contrast should be asked about allergies, especially allergies
to iodine or shellfish. The clients kidney function should also be evaluated to determine if it is safe to
administer contrast during the procedure. Finally, the nurse should ensure that an informed consent is present
because all clients receiving iodine-based contrast must give consent. The CT will have no impact on the
clients breath sounds or hematocrit and hemoglobin levels. Findings from these assessments will not influence
the clients safety during the procedure.

29

. A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in
the nervous system related to aging? (Select all that apply.)
a. Long-term memory loss
b. Slower processing time
c. Increased sensory perception
d. Decreased risk for infection
e. Change in sleep patterns

ANS: B, E
Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception
of pain, and altered balance and/or decreased coordination.

30

A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which
statements should the nurse include when delegating this clients care? (Select all that apply.)
a. Plan to bathe the client in the evening when the client is most alert. b. Encourage the client to use a cane when ambulating. c. Assess the client for symptoms related to pain and discomfort. d. Remind the client to look at foot placement when walking. e. Schedule additional time for teaching about prescribed therapies.

ANS: A, B, D
The nurse should tell the UAP to schedule activities when the client is normally awake, encourage the client to
use a cane when ambulating, and remind the client to look where feet are placed when walking. The nurse
should assess the client for symptoms of pain and should provide sufficient time for older adults to process
information, including new teaching. These are not items the nurse can delegate.