NUR 445-Exam 3 UPDATED ACTUAL
Exam Questions and CORRECT Answers
A client is hospitalized in ICU after a drug overdose. Which statement would the nurse interpret
as indicating the client has normal mentation? (Select all that apply.)
1. "Which part of the hospital am I in?"
2. "I just want to die."
3. "I should have swallowed the pills with bourbon."
4. "Get that cat out of here."
5. "My feet are cold." - CORRECT ANSWER -Answer: 1, 2, 3, 5
A client reports feeling very anxious and not being able to sleep. The nurse anticipates initially
administering a drug from which class to treat these disorders?
1. Opiate narcotics
2. Benzodiazepines
3. Antidepressants
4. Neuromuscular blockers - CORRECT ANSWER -Answer: 2
Which characteristics would the nurse attribute to delirium rather than dementia? (Select all that
apply.)
1. The client's mentation was clear until he was hospitalized last week.
2. The client does not recognize his children.
3. The client has periods of clarity that alternate with confusion.
4. The client's family reports his confusion has become steadily more pronounced over the last
year
5. The client continually tries to get out of bed stating, "I've got to get off this - CORRECT
ANSWER -Answer: 1, 3
A nurse is concerned that a hospitalized client may be developing delirium. Which interventions
are indicated? (Select all that apply.)
,1. Ask the family to bring the client's eyeglasses from home.
2. Turn room lights down at night to encourage sleep.
3. Maintain bed rest until mentation improves.
4. Remove the television from the room.
5. Review the client's medication list. - CORRECT ANSWER -Answer: 1, 2, 5
The nurse discovers a client having a seizure. What should be the nurse's initial action?
1. Roll the client onto his or her side.
2. Intubate the client immediately.
3. Administer pentobarbital.
4. Establish an IV line. - CORRECT ANSWER -Answer: 1
A client experiencing continued seizure activity is to be given propofol. The nurse should
prepare for which other intervention?
1. Administration of insulin
2. Mechanical ventilation
3. Placement of an oral airway
4. Administration of a neuromuscular blocking agent - CORRECT ANSWER -Answer: 2
A client experienced an episode of vision loss and right-side weakness that lasted 4 hours before
totally resolving. What information should the nurse provide to this client?
1. "Your symptoms indicate that you have had a subarachnoid hemorrhage."
2. "While these symptoms have resolved, your risk for a stroke is higher."
3. "These symptoms often occur in older clients and are nothing to worry about."
4. "Your stroke involved the occipital lobe and your vision will dim over the next few weeks." -
CORRECT ANSWER -Answer: 2
A client suffered a stroke yesterday and has recovered partial function. The client's spouse says,
"I don't understand what is happening. When my mother had a stroke, she was left in a coma for
years before she died." What is the nurse's best response?
, 1. "All strokes are different."
2. "Each client responds differently."
3. "There are different levels of damage done by strokes."
4. "Your mother must have had some additional medical problems." - CORRECT
ANSWER -Answer: 3
An 82-year-old African American man has a history of hypertension, type 1 diabetes, and had a
stroke two years ago. He is a smoker and admits to leading a sedentary life style. The nurse
analyzes this information to determine that the client has ________ non-modifiable risk factors
for stroke. - CORRECT ANSWER -4: age, gender, ethnicity, and history of previous
stroke.
A nurse's neighbor calls and reports that her 64-year-old husband is complaining about loss of
vision in one eye after mowing the lawn on a hot Sunday afternoon. He is awake and alert and
says the vision loss came on slowly over about an hour. What advice should the nurse give?
1. "Have him lie down and cool off and see if his vision is better."
2. "Call his physician's answering service and ask them to relay the information to the doctor."
3. "Give him a cold drink and I will be over as soon as I finish lunch to check on him."
4. "Take him to urgent care or the emergency room." - CORRECT ANSWER -Answer: 4
A patient who had a stroke has decreased level of consciousness, headache, and is vomiting.
Using this information, which nursing diagnosis should the nurse assign?
1. Impaired Skin Integrity
2. Acute Pain
3. Decreased Intracranial Adaptive Capacity
4. Activity Intolerance - CORRECT ANSWER -Answer: 3
A client is receiving an infusion of tPA for treatment of acute ischemic stroke. The nurse would
immediately discontinue this infusion if the client manifested which assessment finding? (Select
all that apply.)
1. Nausea
Exam Questions and CORRECT Answers
A client is hospitalized in ICU after a drug overdose. Which statement would the nurse interpret
as indicating the client has normal mentation? (Select all that apply.)
1. "Which part of the hospital am I in?"
2. "I just want to die."
3. "I should have swallowed the pills with bourbon."
4. "Get that cat out of here."
5. "My feet are cold." - CORRECT ANSWER -Answer: 1, 2, 3, 5
A client reports feeling very anxious and not being able to sleep. The nurse anticipates initially
administering a drug from which class to treat these disorders?
1. Opiate narcotics
2. Benzodiazepines
3. Antidepressants
4. Neuromuscular blockers - CORRECT ANSWER -Answer: 2
Which characteristics would the nurse attribute to delirium rather than dementia? (Select all that
apply.)
1. The client's mentation was clear until he was hospitalized last week.
2. The client does not recognize his children.
3. The client has periods of clarity that alternate with confusion.
4. The client's family reports his confusion has become steadily more pronounced over the last
year
5. The client continually tries to get out of bed stating, "I've got to get off this - CORRECT
ANSWER -Answer: 1, 3
A nurse is concerned that a hospitalized client may be developing delirium. Which interventions
are indicated? (Select all that apply.)
,1. Ask the family to bring the client's eyeglasses from home.
2. Turn room lights down at night to encourage sleep.
3. Maintain bed rest until mentation improves.
4. Remove the television from the room.
5. Review the client's medication list. - CORRECT ANSWER -Answer: 1, 2, 5
The nurse discovers a client having a seizure. What should be the nurse's initial action?
1. Roll the client onto his or her side.
2. Intubate the client immediately.
3. Administer pentobarbital.
4. Establish an IV line. - CORRECT ANSWER -Answer: 1
A client experiencing continued seizure activity is to be given propofol. The nurse should
prepare for which other intervention?
1. Administration of insulin
2. Mechanical ventilation
3. Placement of an oral airway
4. Administration of a neuromuscular blocking agent - CORRECT ANSWER -Answer: 2
A client experienced an episode of vision loss and right-side weakness that lasted 4 hours before
totally resolving. What information should the nurse provide to this client?
1. "Your symptoms indicate that you have had a subarachnoid hemorrhage."
2. "While these symptoms have resolved, your risk for a stroke is higher."
3. "These symptoms often occur in older clients and are nothing to worry about."
4. "Your stroke involved the occipital lobe and your vision will dim over the next few weeks." -
CORRECT ANSWER -Answer: 2
A client suffered a stroke yesterday and has recovered partial function. The client's spouse says,
"I don't understand what is happening. When my mother had a stroke, she was left in a coma for
years before she died." What is the nurse's best response?
, 1. "All strokes are different."
2. "Each client responds differently."
3. "There are different levels of damage done by strokes."
4. "Your mother must have had some additional medical problems." - CORRECT
ANSWER -Answer: 3
An 82-year-old African American man has a history of hypertension, type 1 diabetes, and had a
stroke two years ago. He is a smoker and admits to leading a sedentary life style. The nurse
analyzes this information to determine that the client has ________ non-modifiable risk factors
for stroke. - CORRECT ANSWER -4: age, gender, ethnicity, and history of previous
stroke.
A nurse's neighbor calls and reports that her 64-year-old husband is complaining about loss of
vision in one eye after mowing the lawn on a hot Sunday afternoon. He is awake and alert and
says the vision loss came on slowly over about an hour. What advice should the nurse give?
1. "Have him lie down and cool off and see if his vision is better."
2. "Call his physician's answering service and ask them to relay the information to the doctor."
3. "Give him a cold drink and I will be over as soon as I finish lunch to check on him."
4. "Take him to urgent care or the emergency room." - CORRECT ANSWER -Answer: 4
A patient who had a stroke has decreased level of consciousness, headache, and is vomiting.
Using this information, which nursing diagnosis should the nurse assign?
1. Impaired Skin Integrity
2. Acute Pain
3. Decreased Intracranial Adaptive Capacity
4. Activity Intolerance - CORRECT ANSWER -Answer: 3
A client is receiving an infusion of tPA for treatment of acute ischemic stroke. The nurse would
immediately discontinue this infusion if the client manifested which assessment finding? (Select
all that apply.)
1. Nausea
