Exit 21 Flashcards
(34 cards)
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
A. Acute pain related to biologic and chemical factors
B. Anxiety related to change in or threat to health status
C. Hopelessness related to deteriorating physiological condition
D. Risk for Side effects related to medical therapy
A. Acute pain related to biologic and chemical factors
Option A: The priority for interdisciplinary care for the patient experiencing a migraine headache is pain management.
Options B, C, and D: All of the other nursing diagnoses are accurate, but none of them is as urgent as the issue of pain, which is often incapacitating.
Focus: Prioritization
You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? (Choose all that apply).
A. Avoid foods that contain tyramine, such as alcohol and aged cheese.
B. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.
C. Abortive therapy is aimed at eliminating the pain during the aura.
D. A potential side effect of medications is rebound headache.
E. Complementary therapies such as relaxation may be helpful.
F. Continue taking estrogen as prescribed by your physician.
A, B, C, D, and E
Option F: Medications such as estrogen supplements may actually trigger a migraine headache attack.
Options A, B, C, D, and E: All of the other statements are accurate.
Focus: Prioritization
The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?
A. Document the seizure.
B. Perform neurologic checks.
C. Take the patient’s vital signs.
D. Restrain the patient for protection.
C. Take the patient’s vital signs.
Option C: Taking vital signs is within the education and scope of practice for a nursing assistant. The nurse should perform neurologic checks and document the seizure. Patients with seizures should not be restrained; however, the nurse may guide the patientâs movements as necessary.
Focus: Delegation/supervision
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN?
A. Complete admission assessment.
B. Set up oxygen and suction equipment.
C. Place a padded tongue blade at bedside.
D. Pad the side rails before patient arrives.
B. Set up oxygen and suction equipment.
Option B: The LPN/LVN can set up the equipment for oxygen and suctioning.
Option A: The RN should perform the complete initial assessment.
Option C and D: Padded side rails are controversial in terms of whether they actually provide safety and embarrass the patient and family. Tongue blades should not be at the bedside and should never be inserted into the patient’s mouth after a seizure begins.
Focus: Delegation/supervision.
A nursing student is teaching a patient and family about epilepsy prior to the patient’s discharge. For which statement should you intervene?
A. “You should avoid consumption of all forms of alcohol.”
B. “Wear your medical alert bracelet at all times.”
C. “Protect your loved one’s airway during a seizure.”
D. “It’s OK to take over-the-counter medications.”
D. “It’s OK to take over-the-counter medications.”
Option D: A patient with a seizure disorder should not take over-the-counter medications without consulting with the physician first.
Options A, B, and C: The other three statements are appropriate teaching points for patients with seizures disorders and their families.
Focus: Delegation/supervision
A patient with Parkinson’s disease has a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which action must you intervene?
A. The NA assists the patient to ambulate to the bathroom and back to bed.
B. The NA reminds the patient not to look at his feet when he is walking.
C. The NA performs the patient’s complete bath and oral care.
D. The NA sets up the patient’s tray and encourages patient to feed himself.
C. The NA performs the patient’s complete bath and oral care.
Option C: The nursing assistant should assist the patient with morning care as needed, but the goal is to keep this patient as independent and mobile as possible.
Options A, B, and D: Assisting the patient to ambulate, reminding the patient not to look at his feet (to prevent falls), and encouraging the patient to feed himself are all appropriate to goal of maintaining independence.
Focus: Delegation/supervision
The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient indicates that additional teaching is necessary?
A. “I will avoid exercise because the pain gets worse.”
B. “I will use heat or ice to help control the pain.”
C. “I will not wear high-heeled shoes at home or work.”
D. “I will purchase a firm mattress to replace my old one.”
A. “I will avoid exercise because the pain gets worse.”
Option A: Exercises are used to strengthen the back, relieve pressure on compressed nerves and protect the back from re-injury.
Options B and D: Ice, heat, and firm mattresses are appropriate interventions for back pain.
Option C: People with chronic back pain should avoid wearing high-heeled shoes at all times.
Focus: Prioritization
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first?
A. Administer the ordered acetaminophen (Tylenol).
B. Check the Foley tubing for kinks or obstruction.
C. Adjust the temperature in the patient’s room.
D. Notify the physician about the change in status.
Answer: B. Check the Foley tubing for kinks or obstruction.
Option B: These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, or fecal impaction is the first action that should be taken.
Option C: Adjusting the room temperature may be helpful, since too cool a temperature in the room may contribute to the problem.
Option A: Tylenol will not decrease the autonomic dysreflexia that is causing the patient’s headache.
Option D: Notification of the physician may be necessary if nursing actions do not resolve symptoms.
Focus: Prioritization
Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to the neurologic unit?
A. A 28-year-old newly admitted patient with spinal cord injury
B. A 67-year-old patient with stroke 3 days ago and left-sided weakness
C. An 85-year-old dementia patient to be transferred to long-term care today
D. A 54-year-old patient with Parkinson’s who needs assistance with bathing
B. A 67-year-old patient with stroke 3 days ago and left-sided weakness
Option B: The new graduate RN who is oriented to the unit should be assigned stable, non-complex patients, such as the patient with stroke.
Option D: The patient with Parkinson’s disease needs assistance with bathing, which is best delegated to the nursing assistant.
Option A: The patient being transferred to the nursing home and the newly admitted SCI should be assigned to experienced nurses.
Focus: Assignment
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?
A. Determine the level at which the patient has intact sensation.
B. Assess the level at which the patient has retained mobility.
C. Check blood pressure and pulse for signs of spinal shock.
D. Monitor respiratory effort and oxygen saturation level.
D. Monitor respiratory effort and oxygen saturation level.
Option D: The first priority for the patient with an SCI is assessing respiratory patterns and ensuring an adequate airway. The patient with a high cervical injury is at risk for respiratory compromise because the spinal nerves (C3 & 5) innervate the phrenic nerve, which controls the diaphragm.
Options A, B, and C: The other assessments are also necessary, but not as high priority.
Focus: Prioritization
You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursing assistant when providing nursing care for a patient with SCI?
A. Assess patient’s respiratory status every 4 hours.
B. Take patient’s vital signs and record every 4 hours.
C. Monitor nutritional status including calorie counts.
D. Have patient turn, cough, and deep breathe every 3 hours.
B. Take patient’s vital signs and record every 4 hours.
Option B: The nursing assistant’s training and education include taking and recording patient’s vital signs.
Option D: The nursing assistant may assist with turning and repositioning the patient and may remind the patient to cough and deep breathe but does not teach the patient how to perform these actions.
Options A and C: Assessing and monitoring patients require additional education and are appropriate to the scope of practice for professional nurses.
Focus: Delegation/supervision
You are helping the patient with an SCI to establish a bladder-retraining program. What strategies may stimulate the patient to void? (Choose all that apply).
A. Stroke the patient’s inner thigh.
B. Pull on the patient’s pubic hair.
C. Initiate intermittent straight catheterization.
D. Pour warm water over the perineum.
E. Tap the bladder to stimulate detrusor muscle.
A, B, D, and E
Options A, B, D, and E: All of the strategies, except straight catheterization, may stimulate voiding in patients with SCI.
Option C: Intermittent bladder catheterization can be used to empty the patient’s bladder, but it will not stimulate voiding.
Focus: Prioritization
The patient with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this patient the nurse may delegate which action(s) to the LPN/LVN? (Choose all that apply).
A. Check the patient’s skin for pressure form device.
B. Assess the patient’s neurologic status for changes.
C. Observe the halo insertion sites for signs of infection.
D. Clean the halo insertion sites with hydrogen peroxide.
A, C, and D
Options A, C, and D: Checking and observing for signs of pressure or infection are within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide.
Option B: Neurologic examination requires additional education and skill appropriate to the professional RN.
Focus: Delegation/supervision
You are preparing a nursing care plan for the patient with SCI including the nursing diagnosis Impaired Physical Mobility and Self-Care Deficit. The patient tells you, “I don’t know why we’re doing all this. My life’s over.” What additional nursing diagnosis takes priority based on this statement?
A. Risk for Injury related to altered mobility
B. Imbalanced Nutrition, Less Than Body Requirements
C. Impaired Adjustment to Spinal Cord Injury
D. Poor Body Image related to immobilization
C. Impaired Adjustment to Spinal Cord Injury
Option C: The patient’s statement indicates impairment of adjustment to the limitations of the injury and indicates the need for additional counseling, teaching, and support.
Options A, B, and D: The other three nursing diagnoses may be appropriate to the patient with SCI, but they are not related to the patient’s statement.
Focus: Prioritization
Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week?
A. A 34-year-old patient newly diagnosed with multiple sclerosis (MS)
B. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS)
C. A 56-year-old patient with Guillain-Barre syndrome (GBS) in respiratory distress
D. A 25-year-old patient admitted with CA level spinal cord injury (SCI)
B. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS)
Option B: The traveling is relatively new to neurologic nursing and should be assigned patients whose conditions are stable and not complex. The newly diagnosed patient will need to be transferred to the ICU. The patient with C4 SCI is at risk for respiratory arrest.
Options A, C, and D: All three of these patients should be assigned to nurses experienced in neurologic nursing care.
Focus: Assignment
The patient with multiple sclerosis tells the nursing assistant that after physical therapy she is too tired to take a bath. What is your priority nursing diagnosis at this time?
A. Fatigue related to disease state.
B. Activity Intolerance due to generalized weakness.
C. Impaired Physical Mobility related to neuromuscular impairment.
D. Self-care Deficit related to fatigue and neuromuscular weakness.
D. Self-care Deficit related to fatigue and neuromuscular weakness
Option D: At this time, based on the patient’s statement, the priority is Self-Care Deficit related to fatigue after physical therapy.
Options A, B, and C: The other three nursing diagnoses are appropriate to a patient with MS, but they are not related to the patient’s statement.
Focus: Prioritization
The LPN/LVN, under your supervision, is providing nursing care for a patient with GBS. What observation would you instruct the LPN/LVN to report immediately?
A. Complaints of numbness and tingling.
B. Facial weakness and difficulty speaking.
C. Rapid heart rate of 102 beats per minute.
D. Shallow respirations and decreased breath sounds.
D. Shallow respirations and decreased breath sounds
Option D: The priority interventions for the patient with GBS are aimed at maintaining adequate respiratory function. These patients are risk for respiratory failure, which is urgent.
Options A, B, and C: The other findings are important and should be reported to the nurse, but they are not life-threatening.
Focus: Prioritization, delegation/supervision
The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has an elevated temperature (102.20 F), heart rate of 120/minute, rise in blood pressure (158/94), and was incontinent off urine and stool. What is your best first action at this time?
A. Administer an acetaminophen suppository.
B. Notify the physician immediately.
C. Recheck vital signs in 1 hour.
D. Reschedule patient’s physical therapy.
B. Notify the physician immediately.
Option B: The changes that the nursing assistant is reporting are characteristics of myasthenia crisis, which often follows some type of infection. The patient is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the patient’s respiratory status. The patient may need intubation and mechanical ventilation.
Option A: The nurse would notify the physician before giving the suppository because there may be orders for cultures before giving acetaminophen.
Option C: This patient’s vital signs need to be re-checked sooner than 1 hour.
Option D: Rescheduling the physical therapy can be delegated to the unit clerk and is not urgent.
Focus: Prioritization
You are providing care for a patient with an acute hemorrhage stroke. The patient’s husband has been reading a lot about strokes and asks why his wife did not receive alteplase. What is your best response?
A. “Your wife was not admitted within the time frame that alteplase is usually given.”
B. “This drug is used primarily for patients who experience an acute heart attack.”
C. “Alteplase dissolves clots and may cause more bleeding into your wife’s brain.”
D. “Your wife had gallbladder surgery just 6 months ago and this prevents the use of alteplase.”
C. “Alteplase dissolves clots and may cause more bleeding into your wifeâs brain.”
Option C: Alteplase is a clot buster. With patient who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug like alteplase can worsen the bleeding.
Options A, B, and D: The other statements are also accurate about use of alteplase, but they are not pertinent to this patient’s diagnosis.
Focus: Prioritization
You are supervising a senior nursing student who is caring for a patient with a right hemisphere stroke. Which action by the student nurse requires that you intervene?
A. The student instructs the patient to sit up straight, resulting in the patient’s puzzled expression.
B. The student moves the patient’s tray to the right side of her over-bed tray.
C. The student assists the patient with passive range-of-motion (ROM) exercises.
D. The student combs the left side of the patient’s hair when the patient combs only the right side.
A. The student instructs the patient to sit up straight, resulting in the patient’s puzzled expression.
Option A: Patients with right cerebral hemisphere stroke often present with neglect syndrome. They lean to the left and when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse would need to remind the student of this phenomenon and discuss the appropriate interventions.
Focus: Delegation/supervision
Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? (Choose all that apply):
A. Assist patient to reposition every 2 hours.
B. Reapply pneumatic compression boots.
C. Remind patient to perform active ROM.
D. Check extremities for redness and edema.
A, B, and C
Options A, B, and C: The experienced nursing assistant would know how to reposition the patient and how to reapply compression boots, and would remind the patient to perform activities he has been taught to perform.
Option D: Assessing for redness and swelling (signs of deep venous thrombosis {DVT}) requires additional education and still appropriate to the professional nurse.
Focus: Delegation/supervision
The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient?
A. Position the patient sitting up in bed before you feed her.
B. Check the patient’s gag and swallowing reflexes.
C. Feed the patient quickly because there are three more waiting.
D. Suction the patient’s secretions between bites of food.
A. Position the patient sitting up in bed before you feed her.
Option A: Positioning the patient in a sitting position decreases the risk of aspiration.
Option B: The nursing assistant is not trained to assess gag or swallowing reflexes.
Option C: The patient should not be rushed during feeding.
Option D: A patient who needs to be suctioned between bites of food is not handling secretions and is at risk for aspiration. This patient should be assessed further before feeding.
Focus: Delegation/supervision
You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first?
A. Administer codeine 15 mg orally for the patient’s headache.
B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.
D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.
B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
Option B: Untreated bacterial meningitis has a mortality rate approaching 100%, so rapid antibiotic treatment is essential.
Options A, C, and D: The other interventions will help reduce CNS stimulation and irritation and should be implemented as soon as possible.
Focus: Prioritization
You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately?
A. The student enters the room without putting on a mask and gown.
B. The student instructs the family that visits are restricted to 10 minutes.
C. The student gives the patient a warm blanket when he says he feels cold.
D. The student checks the patient’s pupil response to light every 30 minutes.
A. The student enters the room without putting on a mask and gown.
Option A: Meningococcal meningitis is spread through contact with respiratory secretions so use of a mask and gown is required to prevent spread of the infection to staff members or other patients. The other actions may not be appropriate but they do not require intervention as rapidly.
Option B: The presence of a family member at the bedside may decrease patient confusion and agitation.
Option C: Patients with hyperthermia frequently complain of feeling chilled, but warming the patient is not an appropriate intervention.
Option D: Checking the pupil response to light is appropriate, but it is not needed every 30 minutes and is uncomfortable for a patient with photophobia.
Focus: Prioritization
