Which assessments will provide the nurse with the most information regarding a client's neurologic function?
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1. Level of consciousness
2. Doll's eyes reflex
3. Babinski reflex
4. Reaction to painful stimuli
5. Verbal ability
Rationale:
1. & 5. Correct: Yes! The most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and ability to move to command.
2. Incorrect: No, only helps with the determination of brain death.
3. Incorrect: Identifies diseases of the brain and spinal cord.
4. Incorrect: This should be last resort.
Question: 2
Which client should the nurse recognize as being at greatest risk for the development of cancer?
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1. Smoker for 30 plus years
2. Body builder taking steroids and using tanning salons
3. Newborn with multiple birth defects
4. Older individual with acquired immunodeficiency syndrome
Rationale:
4. Correct: Cancer has a high incidence in the immune deficiency client and in the older adult! This one is highest.
1. Incorrect: Not highest, but known environmental carcinogen.
2. Incorrect: Not highest, but known environmental carcinogen.
3. Incorrect: No, birth defects are not a risk factor for cancer.
Question: 3
A client is admitted to the medical unit with persistent vomiting. The client complains of weakness and leg cramps. The wife states that he is irritable. The primary healthcare provider has prescribed lab work and blood gases. Based on this assessment the nurse anticipates which acid base imbalance?
You answered this question Correctly
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Rationale:
4. Correct: Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis.
1. Incorrect: Not respiratory related acid-base imbalance
2. Incorrect: Not respiratory related acid-base imbalance
3. Incorrect: Not acidosis. There is loss of gastric acid and K with persistent vomiting.
Question: 4
A client diagnosed with depression asks the nurse, “What is causing me to be depressed so often?” What is the best response by the nurse?
You answered this question Incorrectly
1. There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain.
2. You experience depression because of your elevated levels of thyroid hormones.
3. The primary healthcare provider will have to explain to you what is causing your depression.
4. Tell me what you think causes you to be depressed?
Rationale:
1. Correct: Decreased levels of norepinephrine, dopamine, and serotonin are neurotransmitter implications for depression.
2. Incorrect: Elevated levels of thyroid hormones are thought to contribute to panic disorder.
3. Incorrect: The nurse can discuss this with the client.
4. Incorrect: This statement may allow for dialog, but does not answer the client's question.
Question: 5
The nurse has just received a client from the special procedures lab for a liver biopsy. What is the position of choice for this client post procedure?
You answered this question Correctly
1. Fowlers
2. Right side
3. Left side
4. Prone
Rationale:
2. Correct: Position client on the liver to hold pressure and stop bleeding.
1. Incorrect: No, this will not help control the bleeding.
3. Incorrect: Oops, the liver is on the right, not the left.
4. Incorrect: No, we don’t turn client onto abdomen.
Question: 6
A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse should anticipate that this client is likely in which acid base imbalance?
You answered this question Incorrectly
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Rationale:
2. Correct: Hyperventilation due to anxiety, pain, shock, severe infection, fever, liver failure can lead to respiratory alkalosis. With each of these, the client has an increased CO2 loss.
1. Incorrect: Not acidosis
3. Incorrect: Not metabolic
4. Incorrect: Not metabolic
Question: 7
What signs or symptoms should the nurse assess for when monitoring a client who has a brain injury?
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1. Increased pulse
2. Glasgow coma score of 15 3. BP 150/60
4. Papilledema
5. Projectile vomiting
Rationale:
3. , 4. & 5. Correct: The pulse pressure of 150/60 is 90 (greater than 40 is a sign of increased ICP). Signs of increased intracranial pressure also include papilledema, elevated systolic pressure, wide pulse pressure, decreased pulse, and slow respirations. Projectile vomiting is classically associated with increased ICP.
1. Incorrect: Decreased pulse, not increased pulse.
2. Incorrect: A score of 15 is the best score a person can get.
Question:
The nurse is caring for a client diagnosed with heart failure who has developed pulmonary edema. Which findings best indicate that the medications are having a therapeutic effect?
Exhibit You answered this question Incorrectly
1. Respiratory rate of 34/min
2. Blood pressure 90/50
3. Urine output of 100 mL over the last hour
4. Apical heart rate of 96/min
5. Blood pressure of 160/90
6. Respiratory rate of 24
Rationale:
3. , 4., 5., & 6. Correct. The heart rate has decreased to within normal range. The blood pressure has decreased, and the urine output has increased.
1. Incorrect. The respiratory rate is still too high, so the pulmonary edema has not resolved.
2. Incorrect. The blood pressure is too low. We worry when the blood pressure gets to 90 systolic.
Question: 9
The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the client's admission signature is legible, however, now observes a jerky, illegible signature. How should the nurse document this handwriting change?
You answered this question Incorrectly
1. Fetor
2. Ataxia
3. Apraxia
4. Asterixis
Rationale:
4. Correct: Yes the liver flap, abnormal muscle tremor, is usually found in clients with diseases of the liver.
1. Incorrect: An offensive odor.
2. Incorrect: Uncoordinated movement.
3. Incorrect: Not using items for their intended purpose.
Question: 10
The nurse is caring for a client diagnosed with major depression post electroconvulsive therapy (ECT). What nursing interventions should be included in this post treatment period?
You answered this question Incorrectly
1. Monitor vital signs every hour for eight hours.
2. Position the client on their side.
3. Stay with the client until fully awake.
4. Provide flexibility in scheduling routine activities.
5. Encourage the client to ambulate in room and hall.
Rationale:
2. & 3. Correct: Positioning on the side will prevent aspiration. Stay with the client until he/she is fully awake, oriented, and able to perform self-care activities without assistance.
1. Incorrect: Pulse, respirations, and blood pressure should be monitored every 15 minutes for the first hour.
4. Incorrect: The client needs a highly structured schedule of routine activities in order to minimize confusion.
5. Incorrect: The client should remain in bed during the immediate post treatment period.
Question: 11
A traumatized soldier goes to the infirmary after being told he almost died in a gun battle. He tells the nurse, “I do not remember any of the details of this event. What is wrong with me?” What is the nurse's best response?
You answered this question Correctly
1. "I understand you are upset, but you will have to go back to your unit sooner or later."
2. "You are repressing this event because it was frightening and painful for you."
3. "In my professional opinion, you are trying to undo what happened in the battle."
4. "You are splitting from the bad you, so that the good you survives."
Rationale:
2. Correct: Repression is the unconscious blocking from awareness material that is threatening or painful. It is the mind’s way of forgetting or experiencing temporary amnesia until it can cope with an overwhelming circumstance.
1. Incorrect: The nurse is being aggressive and judgmental.
3. Incorrect: Undoing is canceling out a behavior or trying to make amends. [Show Less]