Fresno City College - NURSING LV MEDICAL SU; MS WEEK 9 Practice Quiz, LATEST 2021 COMPLETE.

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MS W 9 Practice Quiz Poi nts: 0/1 1. The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should b... e implemented? Select all that apply. Administer intravenous corticosteroids Encourage coughing and deep breathing Provide pureed foods six (6) times a day. Monitor the pulse oximetry reading Assess for autonomic dysreflexia Poi nts: 0/1 2. The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first? Schedule a STAT Magnetic Resonance Imaging of the brain Notify the health-care provider (HCP). Have the client swallow a glass of water Call a Code STROKE Poi nts: 0/1 3. The nurse is caring for a client with a spinal cord injury leaving paralysis. When planning care related to the musculoskeletal system, which considerations are important? Select all that apply. Bone demineralization Limited range of motion Weight bearing Spasticity Contractures Poi nts: 0/1 4. The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved? Venous congestion occurs, causing peripheral edema. Herniation occurs through the foramen magnum. Additional inflammation occurs in the brain. Blood vessels dilate circulating blood. Poi nts: 0/1 5. The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? extradural hematoma epidural hematoma subdural hematoma intracranial hematoma Poi nts: 0/1 6. The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is “brain dead.” Which data support that the client is brain dead? The client assumes decorticate posturing when painful stimuli are applied When the client’s head is turned to the right, the eyes turn to the right. The electroencephalogram (EEG) has identifiable waveforms. No eye activity is observed when the cold caloric test is performed Poi nts: 0/1 7. A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? “I take this when I get a headache.” “It constricts the blood vessels in my head.” “It alleviates my sensitivity to light and sound.” “I use this to prevent migraines.” Poi nts: 0/1 8. The nurse is caring for a client following intracranial surgery. In the plan of care, the nurse states to remove antiembolism stockings. What would the nurse do to accurately complete this intervention? Remove the antiembolism stockings briefly every 8 hours. Remove the antiembolism stockings nightly and reapply by 8 AM. Apply the antiembolism stocking before ambulation daily. Place the antiembolism stockings on the lower extremities as tolerated. Poi nts: 1/1 9. A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? Nausea No bowel movement since yesterday Complaint of headache off and on for past month Frequent voiding Poi nts: 0/1 10. A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply. Percutaneous transluminal coronary artery angioplasty Carotid endarterectomy Administration of tissue plasminogen activator Balloon angioplasty of the carotid artery followed by stent placement Removal of the carotid artery Poi nts: 0/1 11. The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? start an IV with D5W at 100 mL/hr complete a neurological assessment administering a nonnarcotic analgesic prepare for STAT MRI Poi nts: 0/1 12. The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered? Select all that apply. loop diuretics anticunvulsants analgesics corticosteroids antibiotics Poi nts: 0/1 13. The nurse is caring for a client who was discovering unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? A light meal may be eaten if desired. Follow up with regular physician is encouraged. Tylenol may be administered for aches. Observe for any signs of behavioral changes. Poi nts: 1/1 14. The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department? a weak pulse, shallow respirations, and cool pale skin complaints of a headache that resolves with medication a 4 cm area of bright red drainage on the dressing pupils that are equal, react to light, and accomodate Poi nts: 0/1 15. Which nursing assessment finding is most indicative of a hemorrhagic stroke? Sudden onset of breathing alterations Symptoms evolving over 24 to 48 hours Client history of hyperlipidemia Client history of atrial fibrillation Poi nts: 0/1 16. A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? Avoid fiber in the diet. Avoid heavy lifting. Take an antacid frequently. Take an herbal form of feverfew. Poi nts: 0/1 17. A mother brings her 6-year-old child to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be? “A concussion is a blow to the head that is minor and has no real consequences.” “A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull.” “A concussion is a blow to the head that bruises the brain.” “A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain.” Poi nts: 0/1 18. A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best priority nursing action to be taken? Know this is a normal finding for CVA. Perform a vision field assessment. Assist the client with feeding. Reposition the tray and plate. Poi nts: 0/1 19. An elderly client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client? Irregular heart rhythm Becomes confused during the night Bruit heard over carotids Drooling from side of mouth Poi nts: 0/1 20. The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply. prolonged positioning menstruation nausea exposure to flashing light change in environmental temperature red wine Poi nts: 1/1 21. The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/leaking of cerebral spinal fluid (CSF)? Swelling Change in the level of consciousness (LOC) Signs of increased intracranial pressure (IICP) Halo sign Poi nts: 0/1 22. The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first? Set the ventilator to hyperventilate the client in preparation for suctioning Assess the client’s lung sounds and check for peripheral cyanosis Suction the client using the in-line suction, wait 30 seconds, and repeat. Turn the client to the side to allow the secretions to drain from the mouth Poi nts: 0/1 23. Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? Teach Credé’s maneuver to the client needing to void. Observe the client demonstrating self catheterization technique. Assist with bowel training by placing the client on the bedside commode Administer the tube feeding to the client who is quadriplegic. Poi nts: 0/1 24. The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? Encourage the client to remain in the recliner as much as possible Instruct the client to report reddened or irritated skin areas Discuss how to correctly remove the insertion pins. Inform the client that the vest liner cannot be changed Poi nts: 0/1 25. The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? cast turning frame traction with weights and pulleys cervical collar Poi nts: 0/1 26. The nurse is working on a neurosurgical unit. Which of the following nursing interventions are included in the plan of care following spinal surgery? Select all that apply. Coughing and deep breathing Neurovascular assessment of the lower extremity PEARLA Intake and output Monitor vital signs Dressing assessment Poi nts: 1/1 27. The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? An oral proton pump inhibitor An intravenous osmotic diuretic A subcutaneous anticoagulant An oral anticonvulsant Poi nts: 1/1 28. A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse? The client's medications include warfarin. The client is a heart transplant recipient. The client is HIV positive. The client has a history of concussions from playing hockey. Poi nts: 0/1 29. The nurse is caring for a client who has had intracranial surgery and is being discharged home. What instructions would the nurse give the client besides instructions on the medication? You can expect swelling above the incision. Expect sensory changes, such as hearing a clicking sound, around the bone flap. Understand that headaches are uncommon. You can cover the incision with your hair. Poi nts: 0/1 30. The home health nurse is caring for a 28-yearold client with a T10 SCI who says, “I can’t do anything. Why am I so worthless?” Which statement by the nurse would be the most therapeutic? “If you attended a work rehab program you wouldn’t feel worthless.” “Why do you feel worthless? You still have the use of your arms.” “You shouldn’t feel worthless—you are still alive.” “This must be very hard for you. You’re feeling worthless?” Poi nts: 1/1 31. The nurse identifies the concept of intracranial regulation disturbance in a client diagnosed with Parkinson’s Disease. Which priority intervention should the nurse implement? Provide a regular diet of three (3) meals per day. Perform the Braden scale skin assessment. Obtain an order for home health to see the client Keep the bed low and call light in reach Poi nts: 0/1 32. The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? myelography neurologic examination radiography CT scan Poi nts: 0/1 33. The nurse arrives at the site of a one-car motorvehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client’s cervical spine, which action should the nurse take next? Assess the client’s pupils for reaction Attempt to wake the client up by shaking him Assess the client’s airway Carefully remove the driver from the car. Poi nts: 0/1 34. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? a thrombolytic medication an anti-hyperuricemic medication a beta blocker medication an oral anticoagulant medication Poi nts: 0/1 35. A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client? Identify and avoid factors that precipitate or intensify an attack. When an attack occurs, stay in a brightly lit area. Write down any adverse drug effects. Keep a record of activities following an attack. Poi nts: 1/1 36. The concept of intracranial regulation is identified for a client diagnosed with a brain tumor. Which intervention should the nurse include in the client’s plan of care? Maintain the intravenous rate at 150 mL/hour Place the client on seizure precautions Provide a soft, bland diet with three (3) snacks per day. Tell the client to remain on bedrest Poi nts: 0/1 37. The nurse suspects that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? Select all that apply. bladder distension circulatory failure loss of hunger sensation no perspiration below the level of the injury poikilothermia Poi nts: 0/1 38. The client newly diagnosed with Parkinson’s Disease (PD) asks the nurse, “Why can’t I control these tremors?” Which is the nurse’s best response? “The tremors are caused by a lack of the chemical dopamine in the brain; medication may help.” “You are concerned about the tremors? If you want to talk I would like to hear how you feel.” “You can control the tremors when you learn to concentrate and focus on the cause.” “You have too much acetylcholine in your brain causing the tremors but they will get better with time.” Poi nts: 0/1 39. A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of cell transplantation therapy. Which early outcome of treatment is anticipated? Cell transplantation therapy improves the growth of new neurologic connections. Cell transplantation therapy produced a reduction in swelling and pain. Cell transplantation therapy allowed organs to be brought from one person to another. Cell transplantation therapy allows the replacement of nerve cells that are damaged. Poi nts: 0/1 40. The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate? Edema to the head with bruising of the mastoid process Edema to the head with a large scalp laceration Edema to the head with fixed pupils Edema to the head and a blackened eye Poi nts: 0/1 41. The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? The client has cerebral spinal fluid (CSF) leaking from the ear. The client has serous drainage from the nose. The client has an elevated temperature. The client has ecchymosis in the periorbital region. Poi nts: 0/1 42. The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? Assess neurological status Initiate an intravenous access Maintain an adequate airway Monitor pulse, respiration, and blood pressure. Poi nts: 0/1 43. The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae with bone from which location? iliac crest floating rib mandible femur Poi nts: 0/1 44. A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? Headaches are the most common type of reported pain. Cluster headaches can cause severe debilitating pain. Tension headaches are easier to treat. Migraines often coincide with menstrual cycle. Poi nts: 1/1 45. A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility? Keep the client hydrated. Position the client. Help the client perform exercises. Provide a well-balanced diet. Poi nts: 0/1 46. In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock? No reflex activity below the waist Inability to move upper extremities Complaints of a pounding headache Hypotension and bradycardia Poi nts: 0/1 47. A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA? Nausea and vomiting Impaired muscle coordination Severe headache Respiratory distress Poi nts: 0/1 48. Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? Select all that apply. Suction the client every three (3) hours Place the client in Trendelenburg position Position the client with the head of the bed up 30 degrees. Administer soapsuds enemas until clear Cluster activities of care Poi nts: 1/1 49. A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? Prothrombin level Brain CT scan or MRI Lumbar puncture Chest x-ray Poi nts: 0/1 50. A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client? Use caution while driving or performing hazardous activities. Take drugs only after meals at night. Avoid caffeine and alcohol. Avoid crowds. Poi nts: 0/1 51. The nurse is performing a Glascow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client’s GCS one (1) hour ago was scored at 10. Which data indicates the client is improving? The current GSC rating is 12. The current GSC rating is 3. The current GSC rating is 10. The current GSC rating is 9 Poi nts: 0/1 52. The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client’s significant other? awaken the client every two (2) hours monitor for increased intracranial pressure observe frequently for hypervigilence offer the client food every three (3) to four (4) hours Poi nts: 0/1 53. The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? “Do you have trouble hearing?” “Are you allergic to any type of dairy products?” “Are you uncomfortable in closed spaces?” “Have you eaten anything in the last eight (8) hours?” Poi nts: 0/1 54. 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? Transient ischemic attack (TIA) Right-sided cerebrovascular accident (CVA) Completed Stroke Left-sided cerebrovascular accident (CVA) Poi nts: 0/1 55. The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful? Birth via surrogate is best because your baby can be implanted in another woman. Conception is not impaired; the birth process is determined with the physician. Adoption is an option to complete your family but not put your life in jeopardy. Sterilization is best; it would be difficult to care for a baby in your condition. Poi nts: 1/1 56. A client who has experienced an initial transient ischemic attack (TIA) states: “I'm glad it wasn't anything serious.” Which is the best nursing response to this statement? “I sense that you are happy it was not a stroke.” “TIA is a warning sign. Let's talk about lowering your risks.” “People who experience a TIA will develop a stroke.” “TIA symptoms are short lived and resolve within 24 hours.” Poi nts: 0/1 57. While the nurse is making initial rounds after coming on shift, a client thrashes about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having? sinus migraine cluster tension Poi nts: 0/1 58. The nurse is caring for a client with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used? a firm mattress bandages and tape traction equipment a cervical collar Poi nts: 0/1 59. The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? Prepare to administer an antihistamine Place a 2 × 2 gauze under the nose to collect drainage. Test the drainage for presence of glucose Notify the health-care provider immediately Poi nts: 1/1 60. A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client? Impaired Swallowing Risk for Electrolyte Imbalance Risk for Fluid Volume Deficit Altered Nutrition: Less Than Body Requirements Poi nts: 0/1 61. A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? sciatic nerve pain paralysis paresthesia herniation Poi nts: 0/1 62. Which diagnostic evaluation tool would the nurse use to assess the client’s cognitive functioning? Select all that apply. The Functional Independence Measurement Scale (FIMS). The Manic Depression vs Elderly Depression (MDED) scale The Mini-Mental Status Examination (MMSE) scale. The St. Louis University Mental Status (SLUMS) scale The Geriatric Depression Scale (GDS). Poi nts: 1/1 63. Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? subdural intracerebral cerebral epidural Poi nts: 0/1 64. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? the presence of bronchogenic carcinoma a blood glucose level of 480 mg/dL a right-sided carotid bruit a blood pressure of 220/120 mmHg Poi nts: 0/1 65. The client has been diagnosed with a cerebrovascular accident (stroke). The client’s wife is concerned about her husband’s generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? obtain a raised toilet seat for the client's bathroom purchase a long-handled bath sponge for showering obtain a rubber mat to place under the dinner plate purchase clothes with Velcro closure devices Poi nts: 0/1 66. The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. . Encourage the client to move the affected side Turn and reposition the client every shift Instruct the client to hold the fingers in a fist Perform quadriceps exercises three (3) times a day Position the client to prevent shoulder adduction. Poi nts: 1/1 67. The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving? Decerebrate posturing when painful stimuli are applied Purposeless movement in response to painful stimuli. Flaccid paralysis in all four extremities Pupils that are 6 mm in size and nonreactive on painful stimuli Poi nts: 0/1 68. Which priority goal would the nurse identify for a client diagnosed with Parkinson’s Disease (PD)? The client will understand the purpose of medications administered for PD The client will have a home health agency for monitoring at home The client will verbalize feelings about the diagnosis of Parkinson’s Disease The client will be able to maintain mobility and swallow without aspiration Poi nts: 0/1 69. When caring for a client who has had intracranial surgery, what is the most important parameter to monitor? body temperature nutritional status extreme thirst intake and output Poi nts: 0/1 70. The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as “high risk for immobility complications.” Which intervention would be included in the plan of care? Explain all procedures to the client before performing them. Turn the client every shift and massage bony prominences Position the client with the head of the bed elevated at intervals Perform active range-of-motion (ROM) exercises every four (4) hours. Poi nts: 0/1 71. The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first? The client with a concussion The client with a basilar fracture The client with an open head injury The client with a coup injury Poi nts: 0/1 72. The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms? Central nervous system Sympathetic nervous system Peripheral nervous system Autonomic nervous system Poi nts: 0/1 73. The nurse and physician are viewing a brain scan, which indicates bleeding at the point of impact to the skull and edema on the opposite side. The client is sleeping but can be aroused. The client has no memory of accident. The nurse provides all details to the next shift and is most accurate to report which type of injury? contrecoup injury coup injury contusion head injury Poi nts: 0/1 74. The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm? The stimulation can increase intracranial pressure (ICP) or trigger a seizure. The client may become emotional and lose interest in the treatment. The interaction may cause migraine in the client. The interaction may cause the client to become violent. Poi nts: 0/1 75. The male client is admitted to the emergency department following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the emergency department nurse implement in the first five (5) minutes? Select all that apply. Ensure the client has a patent peripheral venous catheter in place Check the client’s driver’s license to see if he will accept blood Contact the organ procurement organization to speak with the family Perform a Glasgow Coma Scale assessment Elevate the head of the bed to 70 degrees Stabilize the client’s neck and spine Poi nts: 0/1 76. The nurse is caring for clients on the rehabilitation unit. Which clients should the nurse assess first after receiving the change of shift report? The client with an L4 SCI who is crying and very upset about being discharged home The client with an L2 SCI who is complaining of a headache and feeling very hot. The client with a T4 SCI who is unable to move the lower extremities The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs Poi nts: 0/1 77. The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement? Keep the client flat in bed. Administer a narcotic analgesic Assess for bladder distention Dim the lights in the room Poi nts: 0/1 78. When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms? Apply cool or warm cloth to head or eyes. Perform stretching exercises and frequent position change. Avoid certain foods. Eliminate use of bright lights when working. Poi nts: 1/1 79. The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders? The first thoracic vertebrae The first lumbar vertebrae The second cervical vertebrae The seventh thoracic vertebrae Poi nts: 0/1 80. The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? The assistant places a hand under the client’s right axilla to move up in bed. The assistant places the client on the back with the client’s head to the side. The assistant praises the client for attempting to perform ADLs independently. The assistant places a gait belt around the client’s waist prior to ambulating. Poi nts: 0/1 81. A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client? Blood pressure 180/98 mm Hg Grade V on the Hunt–Hess Scale Complaint of severe splitting headache Alert and oriented times three Poi nts: 1/1 82. The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? Pulse and blood pressure Numbness and tingling Respiratory pattern Pain level Poi nts: 0/1 83. The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. Administer mild sedatives Maintain the head of the bed at 60 degrees of elevation Administer stool softeners daily Perform deep nasal suction every two (2) hours. Ensure the pulse oximeter reading is higher than 93%. Poi nts: 1/1 84. The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? The client is able to focus and stay on task for 10 minutes The client will return to work within six (6) months The client will regain bowel and bladder control. The client will be able to dress self without assistance Poi nts: 1/1 85. The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? powerlessness sexual dysfunction potential for injury disturbed thought processes Poi nts: 0/1 86. The 80-year-old male client on an Alzheimer’s unit is agitated and asking the nurse to get his father to come and see him. Which is the nurse’s best response? Ask the client to talk about his father with the nurse Tell the client his father is dead and cannot come to see him. Give the client the phone and have him attempt to call his father. Call the family so they can tell the client why his father cannot come to see him Poi nts: 0/1 87. The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report? The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. Poi nts: 0/1 88. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? hemiparesis of the client's left arm and apraxia homonymous hemianopsia and diplopia impulsive behaviour and hostility toward the family paralysis of the right side of the body and ataxia Poi nts: 0/1 89. The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious stating, “What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain.” The nurse is most correct to turn the teaching to which surgical procedure? a laminectomy a diskectomy aggressive traction a spinal fusion Poi nts: 0/1 90. A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of tissue plasminogen activator (TPA) in a client with CVA requires which of the following? Select all that apply. Administer intramuscular for faster response. Used concurrently with heparin therapy Administer within 3 hours of onset of symptoms. Presence of an ischemic stroke The symptoms are no longer evolving. Poi nts: 0/1 91. 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? right-sided left-sided ischemic hemorrhagic Poi nts: 0/1 92. The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care? The client whose father has Parkinson's disease The client who played soccer in college The client who was in a bike accident last summer The client with history of seizures Poi nts: 1/1 93. The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first? Perform a head-to-toe assessment to determine injuries Stabilize the client’s cervical spine Assess the client’s level of consciousness Organize onlookers to remove the client from the lake Poi nts: 0/1 94. The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light-headedness and dizziness. The client’s vital signs are T 99.2°F, P 98, R 24, and BP 84/40. Which action should the nurse implement? Notify the health-care provider as soon as possible (ASAP). Increase the IV rate by 50 mL/hour. Calm the client down by talking therapeutically Lower the head of the bed immediately Poi nts: 0/1 95. A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? maintain the dopamine drip to keep BP at 160/90 monitor neurological status every shift administer a stool softener bid encourage the client to cough hourly Poi nts: 0/1 96. A middle-aged client has scheduled a sick visit to the physician's office, stating symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and identified potential causes of the pain. Which area of the drawing would the nurse emphasize? nucleus pulposus bony vertebrae associated musculature spinal cord pathway Poi nts: 0/1 97. The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? The client's vital signs are temperature, 100.9 °F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. The client prefers to rest in the semi-Fowler's position. The client's level of consciousness has improved. The client has periorbital edema and ecchymosis. Poi nts: 1/1 98. The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement? Refer the client to the state rehabilitation commission. Ask the social worker (SW) about applying for disability. Suggest that the client talk with his significant other about this concern. Refer the client to the American Spinal Cord Injury Association (ASIA Poi nts: 0/1 99. A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. Left-sided hemiplegia Neglect of objects and people on the left side Tendency to distractibility Hyperaware of deficits Impairment of long-term memory Poi nts: 1/1 100. A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? Reduces hypotension Relieves migraines Relaxes muscles Increases appetite Poi nts: 0/1 101. A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy? Anticipate need for endotracheal intubation. Encourage deep breathing and coughing. Resume antilipemic drugs. Observe for facial swelling. Poi nts: 0/1 102. The 28-year-old client is on the rehabilitation unit post spinal cord injury at level T10. Which collaborative team members should participate with the nurse at the case conference? Select all that apply. Occupational Therapist (OT). Physical therapist (PT). Rehabilitation physician Social Worker (SW). Patient care tech (PCT). Registered dietitian (RD Poi nts: 0/1 103. The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement? Perform active lower extremity ROM exercises. Refer to a speech therapist for ventilator assisted speech Administer low-dose subcutaneous anticoagulants. Keep oxygen via nasal cannula on at all times Poi nts: 0/1 104. A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following? Carotid endarterectomy Cholesterol-lowering drugs Monthly prothrombin levels Anticoagulant therapy Poi nts: 1/1 105. A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? prepare to administer recombinant tissue plasminogen activator (rt-PA) discuss the precipitating factors that caused the symptoms schedule for a STAT CT scan of the head notify the speech pathologist for an emergency consult Poi nts: 1/1 106. Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)? a 67-year-old Caucasian male a 84-year-old Japanese female a 55-year-old African American male a 39-year-old pregnant female Poi nts: 0/1 107. The client with a cerebral aneurysm asks the nurse, “What's the big fuss over a headache?” Which is the best response from the nurse regarding to a cerebral aneurysm? “Your physician wants to evaluate the location and condition of the aneurysm.” “Don't worry. The aneurysm has probably been there since birth.” “A headache means your aneurysm is leaking blood into the brain.” “The headache can be an indication that the aneurysm is growing.” Poi nts: 1/1 108. A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? Monitoring is needed as rapid neurologic deterioration may occur. Symptoms will evolve over a period of 1 week. Bleeding continues into the intracerebral area. The crash cart with defibrillator is kept nearby. Poi nts: 0/1 109. The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative Refer the client to an occupational therapist for evaluation. Observe the client swallowing for possible aspiration. Position the client in a semi-Fowler’s position when sleeping. Place a suction setup at the client’s bedside during meals. [Show More]

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