HEMISPHERES VI - HEMORRHAGIC STROKE EXAM
QUESTIONS AND CORRECT ANSWERS {VERIFIED
ANSWERS} |2025 UPLOAD!!
The nurse provides care for a client after an above the knee amputation (AKA) 2
days ago. The nurse places the client in which position?
1.Reverse Trendelenburg position.2.Prone position.3.Lithotomy position.4.High
Fowler position. - ANS -1) This position does not prevent hip contracture and may
greatly increase edema.
2) CORRECT — The client is placed in the prone position for a short time on the
first postoperative day and then for 30 minutes three times a day to stretch the
flexor muscles and prevent hip contracture.
3) This position does not prevent hip contracture.
4) This position does not prevent hip contracture but may actually cause it.
The nurse reviews the care plans of several clients. Which client will the nurse
assess first?
1.Client with a nursing diagnosis of impaired gas exchange.2.Client with a nursing
diagnosis of acute pain.3.Client with a nursing diagnosis of acute
confusion.4.Client with a nursing diagnosis of decreased cardiac output. - ANS -1)
CORRECT - Utilizing Maslow's hierarchy of needs and airway, breathing,
circulation (ABCs), impaired gas exchange will be the highest priority. This client
should be seen first.
2) Acute pain should be addressed, but is not the highest priority. Pain is
considered to be a psychosocial need. Address physical needs first.
3) Acute confusion should be addressed, but is not the highest priority. Confusion
is a psychosocial need. Address physical needs first.
,4) Decreased cardiac output should be addressed, but is not the highest priority.
Airway/ breathing needs come before circulation needs.
The nurse prepares a client for peripheral intravenous catheter placement. Which
factor will the nurse consider when inserting the catheter? (Select all that apply.)
1.Avoid extremities with lymph node removal.2.Place intravenous line on side
that is paralyzed.3.Choose area closest to wrist.4.Choose nondominant arm if
possible.5.Avoid site close to cellulitis. - ANS -1) CORRECT— Extremities with
lymph node removal should be avoided to prevent the development of
lymphedema.
2) Intravenous catheters should not be placed in a paralyzed limb because of
alteration in sensation.
3) Areas of flexion and extension, such as the wrist, should be avoided.
4) CORRECT— A nondominant arm prevents displacement of the catheter.
5) CORRECT— Areas of infection should be avoided.
The nurse provides care for a client newly diagnosed with a benign brain tumor.
The nurse teaches the client about the diagnosis. Which property of benign
tumors should the nurse include in the teaching?
1.They are poorly differentiated.2.They metastasize to other organs.3.They grow
at an aggressive rate.4.They can cause tissue destruction. - ANS -1) Malignant
tumors are poorly differentiated. Benign tumors are more differentiated, meaning
they more closely resemble the cells of the tissue from which they arose.
2) Benign tumors are not able to metastasize.
3) Not all tumors, benign or malignant, grow aggressively; some are indolent, or
slow growing.
4) CORRECT - Benign tumors can cause tissue destruction by the size and location
in the body.
,The nurse plans to assess a client with acquired immune deficiency syndrome
(AIDS). Which question provides the least amount of information to plan this
client's care?
1.What method of birth control do you use?2.Do you use intravenous
drugs?3.How many sexual partners do you have?4.How old were you when you
became sexually active? - ANS -1) Information about birth control is important to
prevent a baby from being born with the AIDS virus.
2) Intravenous drug use is a risk factor for AIDS.
3) Sexual partners is a risk factor for AIDS.
4) CORRECT - Asking about the age when sexual activity started is not relevant
because it does not provide any information related to the presence of risk
factors for AIDS.
The charge nurse takes a brief report from a nurse assigned to a client just
admitted with a deep vein thrombosis (DVT). Which statement requires
immediate follow up by the charge nurse?
1.The client's left leg is warm, enlarged, and painful.2.The client ambulated to the
bathroom without difficulty.3.The client plays tennis weekly.4.The client has a
history of bipolar disorder and depression. - ANS -1) The client admitted for a
deep venous thrombosis (DVT) is expected to experience symptoms of a DVT,
such as a warm, swollen, and painful extremity.
2) CORRECT - The client should not ambulate until the DVT is resolving well, which
usually takes a few days. Evidence that the client is anticoagulated, such as
coagulation lab values, is also needed.
3) It is not relevant that the client normally plays tennis.
4) The client's history of a mental health disorder needs follow up to ensure the
correct medications are prescribed, but it is not the immediate concern.
The nurse assess a pregnant client at 10 weeks gestation. Which finding is
consistent with the gestational age of the fetus?
, 1.A ballottement occurs during a pelvic examination.2.A fetal heartbeat can be
heard with a Doppler.3.The systolic blood pressure has increased 15 mm Hg
above baseline.4.The client reports feeling quickening in the lower abdomen. -
ANS -1) A sudden tap on the cervix during vaginal examination may cause a fetus
to rise in amniotic fluid and then rebound to original position. This is referred to
as a ballottment and occurs near mid-pregnancy, not at 10 weeks.
2) CORRECT - The fetal heartbeat may be detected as early as 10 weeks using a
Doppler device.
3) The mother's systolic pressure would not expect to increase at this point in the
pregnancy. This is not an expected finding.
4) Quickening, a fetal movement felt by mother, is first perceived at 16 to 20
weeks as a faint fluttering in the lower abdomen.
During an assessment the nurse suspects that an injured child is a victim of
physical abuse. Which action is the nurse's primary legal responsibility in this
situation?
1.Refer the family to the hospital social worker.2.Call the hospital attorney to
report the suspicion.3.Report the case to the local law enforcement
authorities.4.Document the physical assessment of the child accurately and
thoroughly. - ANS -1) Referring the family to the hospital social worker is not the
nurse's legal responsibility.
2) It is not the nurse's legal responsibility to report the suspicion to the hospital
attorney.
3) CORRECT — Nurses are obligated to report suspected child abuse to local
authorities.
4) This is the nurse's professional responsibility, but the primary legal
responsibility is to report the abuse to the local authorities.
A client experiencing insomnia asks if there are any dietary modifications that can
help improve sleep. Which response by the nurse is best?
QUESTIONS AND CORRECT ANSWERS {VERIFIED
ANSWERS} |2025 UPLOAD!!
The nurse provides care for a client after an above the knee amputation (AKA) 2
days ago. The nurse places the client in which position?
1.Reverse Trendelenburg position.2.Prone position.3.Lithotomy position.4.High
Fowler position. - ANS -1) This position does not prevent hip contracture and may
greatly increase edema.
2) CORRECT — The client is placed in the prone position for a short time on the
first postoperative day and then for 30 minutes three times a day to stretch the
flexor muscles and prevent hip contracture.
3) This position does not prevent hip contracture.
4) This position does not prevent hip contracture but may actually cause it.
The nurse reviews the care plans of several clients. Which client will the nurse
assess first?
1.Client with a nursing diagnosis of impaired gas exchange.2.Client with a nursing
diagnosis of acute pain.3.Client with a nursing diagnosis of acute
confusion.4.Client with a nursing diagnosis of decreased cardiac output. - ANS -1)
CORRECT - Utilizing Maslow's hierarchy of needs and airway, breathing,
circulation (ABCs), impaired gas exchange will be the highest priority. This client
should be seen first.
2) Acute pain should be addressed, but is not the highest priority. Pain is
considered to be a psychosocial need. Address physical needs first.
3) Acute confusion should be addressed, but is not the highest priority. Confusion
is a psychosocial need. Address physical needs first.
,4) Decreased cardiac output should be addressed, but is not the highest priority.
Airway/ breathing needs come before circulation needs.
The nurse prepares a client for peripheral intravenous catheter placement. Which
factor will the nurse consider when inserting the catheter? (Select all that apply.)
1.Avoid extremities with lymph node removal.2.Place intravenous line on side
that is paralyzed.3.Choose area closest to wrist.4.Choose nondominant arm if
possible.5.Avoid site close to cellulitis. - ANS -1) CORRECT— Extremities with
lymph node removal should be avoided to prevent the development of
lymphedema.
2) Intravenous catheters should not be placed in a paralyzed limb because of
alteration in sensation.
3) Areas of flexion and extension, such as the wrist, should be avoided.
4) CORRECT— A nondominant arm prevents displacement of the catheter.
5) CORRECT— Areas of infection should be avoided.
The nurse provides care for a client newly diagnosed with a benign brain tumor.
The nurse teaches the client about the diagnosis. Which property of benign
tumors should the nurse include in the teaching?
1.They are poorly differentiated.2.They metastasize to other organs.3.They grow
at an aggressive rate.4.They can cause tissue destruction. - ANS -1) Malignant
tumors are poorly differentiated. Benign tumors are more differentiated, meaning
they more closely resemble the cells of the tissue from which they arose.
2) Benign tumors are not able to metastasize.
3) Not all tumors, benign or malignant, grow aggressively; some are indolent, or
slow growing.
4) CORRECT - Benign tumors can cause tissue destruction by the size and location
in the body.
,The nurse plans to assess a client with acquired immune deficiency syndrome
(AIDS). Which question provides the least amount of information to plan this
client's care?
1.What method of birth control do you use?2.Do you use intravenous
drugs?3.How many sexual partners do you have?4.How old were you when you
became sexually active? - ANS -1) Information about birth control is important to
prevent a baby from being born with the AIDS virus.
2) Intravenous drug use is a risk factor for AIDS.
3) Sexual partners is a risk factor for AIDS.
4) CORRECT - Asking about the age when sexual activity started is not relevant
because it does not provide any information related to the presence of risk
factors for AIDS.
The charge nurse takes a brief report from a nurse assigned to a client just
admitted with a deep vein thrombosis (DVT). Which statement requires
immediate follow up by the charge nurse?
1.The client's left leg is warm, enlarged, and painful.2.The client ambulated to the
bathroom without difficulty.3.The client plays tennis weekly.4.The client has a
history of bipolar disorder and depression. - ANS -1) The client admitted for a
deep venous thrombosis (DVT) is expected to experience symptoms of a DVT,
such as a warm, swollen, and painful extremity.
2) CORRECT - The client should not ambulate until the DVT is resolving well, which
usually takes a few days. Evidence that the client is anticoagulated, such as
coagulation lab values, is also needed.
3) It is not relevant that the client normally plays tennis.
4) The client's history of a mental health disorder needs follow up to ensure the
correct medications are prescribed, but it is not the immediate concern.
The nurse assess a pregnant client at 10 weeks gestation. Which finding is
consistent with the gestational age of the fetus?
, 1.A ballottement occurs during a pelvic examination.2.A fetal heartbeat can be
heard with a Doppler.3.The systolic blood pressure has increased 15 mm Hg
above baseline.4.The client reports feeling quickening in the lower abdomen. -
ANS -1) A sudden tap on the cervix during vaginal examination may cause a fetus
to rise in amniotic fluid and then rebound to original position. This is referred to
as a ballottment and occurs near mid-pregnancy, not at 10 weeks.
2) CORRECT - The fetal heartbeat may be detected as early as 10 weeks using a
Doppler device.
3) The mother's systolic pressure would not expect to increase at this point in the
pregnancy. This is not an expected finding.
4) Quickening, a fetal movement felt by mother, is first perceived at 16 to 20
weeks as a faint fluttering in the lower abdomen.
During an assessment the nurse suspects that an injured child is a victim of
physical abuse. Which action is the nurse's primary legal responsibility in this
situation?
1.Refer the family to the hospital social worker.2.Call the hospital attorney to
report the suspicion.3.Report the case to the local law enforcement
authorities.4.Document the physical assessment of the child accurately and
thoroughly. - ANS -1) Referring the family to the hospital social worker is not the
nurse's legal responsibility.
2) It is not the nurse's legal responsibility to report the suspicion to the hospital
attorney.
3) CORRECT — Nurses are obligated to report suspected child abuse to local
authorities.
4) This is the nurse's professional responsibility, but the primary legal
responsibility is to report the abuse to the local authorities.
A client experiencing insomnia asks if there are any dietary modifications that can
help improve sleep. Which response by the nurse is best?
