rev finals part 1

Question 1

A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first?

a. Obtain two sets of blood cultures.
b. Administer the prescribed IV vancomycin (Vancocin).
c. Obtain central venous pressure (CVP) measurements.
d. Administer the prescribed IV norepinephrine (Levophed)

Answer 1

a. Obtain two sets of blood cultures.

(Blood cultures should be obtained before IV antibiotics are started. )

Question 2

The emergency department nurse is triaging clients. Which client does the nurse assess most carefully for hypovolemic shock?

a. 15-year-old adolescent who plays high school basketball
b. 24-year-old computer specialist who has bulimia
c. 48-year-old truck driver who has a 40-pack-year history of smoking
d. 62-year-old business executive who travels frequently

Answer 2

b. 24-year-old computer specialist who has bulimia

(Hypovolemic shock can be caused by dehydration. )

Question 3

A client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How does the nurse document this seizure activity?

a. Atonic seizure
b. Absence seizure
c. Myoclonic seizure
d. Tonic-clonic seizure

Answer 3

d. Tonic-clonic seizure

(Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure.)

Question 4

The nurse is assessing a client with a history of absence seizures. Which clinical manifestation does the nurse assess for?

a. Automatisms
b. Intermittent rigidity
c. Sudden loss of muscle tone
d. Brief jerking of the extremities

Answer 4

a. Automatisms

Automatisms are characteristic of absence seizures.

Question 5

The nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What is the nurse’s priority action?

a. Restrain the client’s extremities.
b. Turn the client’s head to the side.
c. Take the client’s blood pressure.
d. Place an airway into the client’s mouth.

Answer 5

b. Turn the client’s head to the side.

Question 6

A client is actively experiencing status epilepticus. Which prescribed medication does the nurse prepare to administer?

a. Atropine
b. Lorazepam (Ativan)
c. Phenytoin (Dilantin)
d. Morphine sulfate

Answer 6

b. Lorazepam (Ativan)

Question 7

The nurse is teaching a client who is newly diagnosed with epilepsy. Which statement by the client indicates a need for further teaching concerning the drug regimen?

a. “I will not drink any alcoholic beverages.”
b. “I will wear a medical alert bracelet.”
c. “I will let my doctor know about all of my prescriptions.”
d. “I can skip a couple of pills if they make me ill.”

Answer 7

d. “I can skip a couple of pills if they make me ill.”

Question 8

A client with new-onset status epilepticus is prescribed phenytoin (Dilantin). After teaching the client about this treatment regimen, the nurse assesses the client’s understanding. Which statement indicates that the client understands the teaching?

a. “I must drink at least 2 liters of water daily.”
b. “This will stop me from getting an aura before a seizure.”
c. “I will not be able to be employed while taking this medication.”
d. “Even when my seizures stop, I will take this drug.”

Answer 8

d. “Even when my seizures stop, I will take this drug.”

Question 9

The daughter of a client with Alzheimer’s disease asks, “Will the medication my mother is taking improve her dementia?” How does the nurse respond?

a. “It will help your mother live independently once more.”
b. “It is used to halt the advancement of Alzheimer’s disease but will not cure it.”
c. “It will provide a steady improvement in memory but not in problem solving.”
d. “It will not improve dementia but can help control emotional responses.”

Answer 9

d. “It will not improve dementia but can help control emotional responses.”

(Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer’s disease.)

Question 10

A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse’s first action?

a. Palpate the area over the bladder for distention.
b. Place the client in the Trendelenburg position.
c. Administer oxygen via a nasal cannula.
d. Perform bilateral carotid massage.

Answer 10

a. Palpate the area over the bladder for distention.

(The client is manifesting symptoms of autonomic dysreflexia.)

Question 11

Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time?

a. Level of consciousness and orientation
b. Heart rate and rhythm
c. Muscle strength and reflexes
d. Respiratory pattern and airway

Answer 11

d. Respiratory pattern and airway

Question 12

A client who experienced a spinal cord injury 1 hour ago is brought to the emergency department. Which prescribed medication does the nurse prepare to administer to this client?

a. Intrathecal baclofen (Lioresal)
b. Methylprednisolone (Medrol)
c. Atropine sulfate
d. Epinephrine (Adrenalin)

Answer 12

b. Methylprednisolone

(Methylprednisolone should be given within 8 hours of the injury.)

Question 13

The nurse is caring for a client with a lower motor neuron lesion who wishes to achieve bladder control. Which intervention does the nurse implement to effectively stimulate the initiation of voiding for this client?

a. Stroking the inner aspect of the thigh
b. Intermittent catheterization
c. Digital anal stimulation
d. The Valsalva maneuver

Answer 13

d. The Valsalva maneuver

Question 14

A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern. Which action does the nurse implement to assist in relieving this client’s constipation?

a. Pouring warm water over the perineum
b. Tapping the abdomen from left to right
c. Administering daily tap water enemas
d. Implementing a consistent daily time for elimination

Answer 14

d. Implementing a consistent daily time for elimination

Question 15

A client with paraplegia is scheduled to participate in a rehabilitation program. The client states, “I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better.” How does the nurse respond?

a. “If you do not want to participate in the rehabilitation program, I will cancel the order.”
b. “Your doctor has helped many clients with your injury and has ordered a rehabilitation program to help you.”
c. “The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability.”
d. “When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.”

Answer 15

c. “The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability.”

Question 16

The nurse is teaching a client who has a spinal cord injury how to prevent respiratory problems at home. Which statement indicates that the client correctly understands the teaching?

a. “I will use my incentive spirometer every 2 hours while I’m awake.”
b. “I will not drink thick fluids to prevent choking.”
c. “I will take cough medicine to prevent excessive coughing.”
d. “I will position myself on my right side so I don’t aspirate.”

Answer 16

a. “I will use my incentive spirometer every 2 hours while I’m awake.”

Question 17

A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication does the nurse prepare to administer?

a. Baclofen (Lioresal)
b. Interferon beta-1b (Betaseron)
c. Dantrolene sodium (Dantrium)
d. Methylprednisolone (Medrol)

Answer 17

d. Methylprednisolone (Medrol)

Question 18

A client with multiple sclerosis is being treated with fingolimod (Gilenya). Which clinical manifestation alerts the nurse to an adverse effect of this medication?

a. Periorbital edema
b. Black tarry stools
c. Bradycardia
d. Vomiting after meals

Answer 18

c. Bradycardia

Question 19

The nurse is preparing a client who has multiple sclerosis (MS) for discharge home from a rehabilitation center. The client has been prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which instruction does the nurse include in the teaching plan for the client?

a. “Take warm baths to promote muscle relaxation.”
b. “Avoid crowds and people with colds.”
c. “Use physical aids such as walkers as little as possible.”
d. “Stop using these medications when your symptoms improve.”

Answer 19

b. “Avoid crowds and people with colds.”

( these medications are immunosuppressive. Warm baths will exacerbate the MS symptoms, assistive devices )

Question 20

Early manifestations of amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) are somewhat similar. Which clinical feature of ALS distinguishes it from MS?

a. Dysarthria
b. Dysphagia
c. Muscle weakness
d. Impairment of respiratory muscles

Answer 20

d. Impairment of respiratory muscles

In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, and this leads to respiratory compromise.

Question 21

A client is scheduled for magnetic resonance imaging (MRI). Which action does the nurse implement before the test?

a. Ensure that the person does not eat for 8 hours before the procedure.
b. Discontinue all neuroactive medications 3 hours before the procedure.
c. Make sure that the client has an identification bracelet that cannot be removed.
d. Replace the client’s gown with metal snaps with one that has cloth ties.

Answer 21

d. Replace the client’s gown with metal snaps with one that has cloth ties.

Question 22

The nurse is planning care for a client who has a spinal cord injury. Which interdisciplinary team member does the nurse consult with to assist the client with activities of daily living?

a. Social worker
b. Physical therapist
c. Occupational therapist
d. Case manager

Answer 22

c. Occupational therapist

Question 23

The nurse is discussing advanced directives with a client who has amyotrophic lateral sclerosis (ALS). The client states, “I do not want to be placed on a mechanical ventilator.” How does the nurse respond?

a. “You will need to discuss that with your family and health care provider.”
b. “Why are you afraid of being placed on a breathing machine?”
c. “What would you like to be done if you begin to have difficulty breathing?”
d. “You will be on the ventilator only until your muscles get stronger.”

Answer 23

c. “What would you like to be done if you begin to have difficulty breathing?”

Question 24

The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome?

a. Nerve impulses are not transmitted to skeletal muscle.
b. The immune system destroys the myelin sheath.
c. The distal nerves degenerate and retract.
d. Antibodies to acetylcholine receptor sites develop.

Answer 24

b. The immune system destroys the myelin sheath.

Question 25

The nurse assesses a client who has Guillain-Barré syndrome. Which clinical manifestation does the nurse expect to find in this client? a. Ophthalmoplegia and diplopia b. Progressive weakness without sensory involvement c. Progressive, ascending weakness and paresthesia d. Weakness of the face, jaw, and sternocleidomastoid muscles

Answer 25

c. Progressive, ascending weakness and paresthesia

Question 26

The nurse reviews laboratory data for a client who has Guillain-Barré syndrome (GBS). Which result does the nurse correlate with this disease process? a. Increased cerebrospinal fluid (CSF) protein level b. Decreased serum protein electrophoresis results c. Increased antinuclear antibodies d. Decreased immune globulin G (IgG) levels

Answer 26

a. Increased cerebrospinal fluid (CSF) protein level

Question 27

A client who has Guillain-Barré syndrome is scheduled for plasmapheresis. Before the procedure, which clinical manifestation does the nurse use to determine patency of the client's arteriovenous shunt? a. Palpable distal pulses b. A pink, warm extremity c. The presence of a bruit d. Shunt pressure higher than 25 mm Hg

Answer 27

c. The presence of a bruit

Question 28

The nurse assesses a client with Guillain-Barré syndrome during plasmapheresis. Which complication does the nurse monitor for during this procedure? a. Tachycardia b. Hypovolemia c. Hyperkalemia d. Hemorrhage

Answer 28

b. Hypovolemia

Question 29

The nurse teaches a client with Guillain-Barré syndrome (GBS) about the recovery rate of this disorder. Which statement indicates that the client correctly understands the teaching? a. "I need to see a lawyer because I do not expect to recover from this disease." b. "I will have to take things slowly for several months after I leave the hospital." c. "I expect to be able to return to work in construction soon after I get discharged." d. "I wonder if my family will be able to manage my care now that I am paralyzed."

Answer 29

b. "I will have to take things slowly for several months after I leave the hospital."

Question 30

The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? a. Inability to perform the six cardinal positions of gaze b. Lateralization to the affected side during the Weber test c. Absent deep tendon reflexes d. Impaired stereognosis

Answer 30

a. Inability to perform the six cardinal positions of gaze

Question 31

The nurse is assessing laboratory results for a client with myasthenia gravis (MG). Which results does the nurse correlate with this disease process? a. Elevated serum calcium level b. Decreased thyroid hormone level c. Decreased complete blood count d. Elevated acetylcholine receptor antibody levels

Answer 31

d. Elevated acetylcholine receptor antibody levels

Question 32

A client suspected to have myasthenia gravis is scheduled for the Tensilon (edrophonium chloride) test. Which prescribed medication does the nurse prepare to administer if complications of this test occur? a. Epinephrine b. Atropine sulfate c. Diphenhydramine d. Neostigmine bromide

Answer 32

b. Atropine sulfate

Question 33

The nurse is caring for a client who has myasthenia gravis. Which nursing intervention does the nurse implement to reduce muscle weakness in this client? a. Administer a therapeutic massage. b. Collaborate with the physical therapist. c. Perform passive range-of-motion exercises. d. Reposition the client every 2 hours.

Answer 33

b. Collaborate with the physical therapist.

Question 34

The nurse is assessing a client who is experiencing a myasthenia crisis. Which diagnostic test does the nurse anticipate being ordered? a. Babinski reflex test b. Tensilon test c. Cholinesterase challenge test d. Caloric reflex test

Answer 34

b. Tensilon test

Question 35

A client who has myasthenia gravis is receiving atropine for a cholinergic crisis. Which intervention does the nurse implement for this client? a. Suction the client to remove secretions. b. Turn and reposition the client every 2 hours. c. Measure urinary output every 30 minutes. d. Administer prescribed anticholinergic drugs as needed.

Answer 35

a. Suction the client to remove secretions.

Question 36

The nurse instructs a client who has myasthenia gravis to take prescribed medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase drugs. The client asks why the timing of meals is so important. Which is the nurse's best response? a. "This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke." b. "This timing prevents your blood sugar level from dropping too low and causing you to be at risk for falling." c. "These drugs are very irritating to your stomach and could cause ulcers if taken too long before meals." d. "These drugs cause nausea and vomiting. By waiting a while after you take the medication, you are less likely to vomit."

Answer 36

c. "These drugs are very irritating to your stomach and could cause ulcers if taken too long before meals."

Question 37

A client who has myasthenia gravis is recovering after a thymectomy. Which complication does the nurse monitor for in this client? a. Sudden onset of shortness of breath b. Swelling of the lower extremities c. Lower abdominal tenderness d. Decreased urinary output

Answer 37

a. Sudden onset of shortness of breath

Question 38

A client with myasthenia gravis is preparing for discharge. Which instructions does the nurse include when educating the client's family members or caregiver? a. Technique for therapeutic massage to the lower extremities b. Administration of morphine sulfate via an IV pump c. Instructions for preparing thin, puréed foods d. Cardiopulmonary resuscitation (CPR)

Answer 38

d. Cardiopulmonary resuscitation (CPR)

Question 39

The nurse teaches a client who has autonomic dysfunction about injury prevention. Which statement indicates that the client correctly understands the teaching? a. "I will change positions slowly." b. "I will avoid wearing cotton socks." c. "I will use an electric razor." d. "I will use a heating pad on my feet."

Answer 39

a. "I will change positions slowly."

Question 40

The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan? a. "Cut all calluses and corns from your feet as soon as you notice them." b. "Your balance will be steadier if you go barefoot while at home." c. "Use a thermometer to check the temperature of bath water." d. "Avoid using lotion on the feet and legs."

Answer 40

c. "Use a thermometer to check the temperature of bath water."

Question 41

The nurse teaches a client who has Guillain-Barré syndrome (GBS) about pain management. Which statement indicates that the client correctly understands the teaching? a. "I can use the button on the pump as often as I want to get more pain medication." b. "Aspirin will provide the best relief from my pain associated with this disease." c. "A combination of morphine and distraction helps bring me relief right now." d. "I should not have any pain as a result of impaired motor and sensory neurons."

Answer 41

c. "A combination of morphine and distraction helps bring me relief right now."

Question 42

The nurse is obtaining a health history for a 45-year-old woman with Guillain-Barré syndrome (GBS). Which statement by the client does the nurse correlate with the client's diagnosis? a. "My neighbor also had Guillain-Barré syndrome." b. "I had a viral infection about 2 weeks ago." c. "I am an artist and work with oil paints." d. "I have a history of a cardiac dysrhythmia."

Answer 42

b. "I had a viral infection about 2 weeks ago."

Question 43

The nurse is obtaining a health history for a client admitted to the hospital after experiencing a brain attack. Which disorder does the nurse identify as a predisposing factor for an embolic stroke? a.Seizures b.Psychotropic drug use c. Atrial fibrillation d.Cerebral aneurysm

Answer 43

c.Atrial fibrillation

Question 44

A client with aphasia presents to the emergency department with a suspected brain attack. Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic stroke? a.Two episodes of speech difficulties in the last month b.Sudden loss of motor coordination c.A grand mal seizure 2 months ago d.Chest pain and nuchal rigidity

Answer 44

a.Two episodes of speech difficulties in the last month (Thrombotic stroke is characterized by a gradual onset of symptoms that often are preceded by transient ischemic attacks (TIAs), causing a focal neurologic dysfunction. )

Question 45

The nurse is caring for an 80-year-old client who presented to the emergency department in a coma. Which question does the nurse ask the client's family to help determine whether the coma is related to a brain attack? a."How many hours does your mother usually sleep at night?" b."Did your mother complain recently of weakness in her lower extremities?" c."Is any history of seizures known among your mother's immediate family?" d."Does your mother drink any alcohol or take any medications?"

Answer 45

d."Does your mother drink any alcohol or take any medications?" (Conditions such as drug or alcohol intoxication, as well as hypoxemia and metabolic disturbances, can cause profound changes in level of consciousness (LOC) when accompanied by a brain attack.)

Question 46

The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client? a.Impaired proprioception b.Aphasia c.Agraphia d.Impaired olfaction

Answer 46

a.Impaired proprioception (A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness.)

Question 47

A client who had a stroke combs her hair only on the right side of her head and washes only the right side of her face. How does the nurse interpret these actions? a.Poor left-sided motor control b.Paralysis or contractures on the right side c.Limited visual perception of the left fields d.Unawareness of the existence of her left side

Answer 47

d.Unawareness of the existence of her left side (Clients who have experienced a right hemisphere stroke often have neglect syndrome, in which they are unaware of the existence of the paralyzed side, or the left side. )

Question 48

The nurse notes that the left arm of a client who has experienced a brain attack is in a contracted, fixed position. Which complication of this position does the nurse monitor for in this client? a.Shoulder subluxation b.Flaccid hemiparesis c.Pathologic fracture d.Neglect syndrome

Answer 48

a.Shoulder subluxation (Hypertonia causing contracture or flaccidity can predispose the client to subluxation of the shoulder.)

Question 49

The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications? a.Administer prescribed analgesics to promote pain relief. b.Cluster nursing procedures together to avoid fatiguing the client. c.Monitor neurologic and vital signs closely to identify early changes in status. d.Position with the head of the bed flat to enhance cerebral perfusion.

Answer 49

c.Monitor neurologic and vital signs closely to identify early changes in status. Early detection of neurologic, blood pressure, and heart rhythm changes offers an opportunity to intervene in a timely fashion.

Question 50

A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit. Which prescribed medication does the nurse prepare to administer? a.Tissue plasminogen activator b.Heparin sodium c.Gabapentin (Neurontin) d.Warfarin (Coumadin)

Answer 50

a.Tissue plasminogen activator The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery occlusion and re-establish blood flow.