NUR480 EXAM 3 QUESTIONS WITH
COMPLETE UPGRADED ACCURATE
ANSWERS .100% ACCURATE
In planning for discharge planning for a client with bacterial meningitis, the nurse will be sure to include
which instruction?
1. Keep all family and visitors from visiting your room for protective isolation.
2. Make sure you eat high protein diet with plenty of fluids
3. Take all of the antibiotics until gone.
4. Incorporate regular exercise with an active range of motion. - answer ✔✔-3. Take all of the antibiotics
until gone.
The client should be instructed to complete all antibiotics until they are completely gone. Failure to
complete antibiotics may lead to re-infection and may spread causing endocarditis and other infections
in the body, especially if the bacteria were from streptococci. While the client may be in isolation while
in the hospital, family may not need to quarantine the client when at home. Some family members
receive prophylactic antibiotics, but will be ordered according to the bacterial strain and health care
provider (HCP) recommendations. It is important to eat a good diet, but the most important will be
taking prescribed antibiotics. While returning to exercise is important, gradual increase should be
performed, and the answer selection for exercise was not as important as prescribed antibiotics.
The nurse is assessing the central stimulus function of an unconscious client in the intensive care unit.
The nurse should plan to use which technique to test the client's central response to stimuli?
1. Supraorbital ridge pressure.
2. Sternal rub.
3. Pressure on the nail bed.
4. Calling out loudly close to the client's ear. - answer ✔✔-1. Supraorbital ridge pressure.
,Central stimulus is applied to cranial nerves not peripheral nerves. Supraorbital ridge pressure by
applying pressure on the orbital rim is indicated for central stimulus assessment. Sternal rub is usually
not indicated via best practices. Pressure on the nail bed represents testing painful stimuli for motor
testing on peripheral nerves. Calling out loudly is not an assessment technique for central stimulus
function. There are two anatomic locations for pain stimulus: centrally and peripherally. Central involves
trapezious pinch or supraorbital pressure whereas peripheral stimuli are applied to extremities.
Responses may infer damage to the brain or specific brain areas.
A client is admitted for observation following a motor vehicle accident that occurred on the way to the
client's daughter's wedding. The next morning, instead of asking about the wedding, the client tells the
nurse "I have to leave now since the wedding is in a few minutes." The client then becomes agitated
when the nurse re-orients and states the actual date (which is the day following the wedding). What
should the nurse do next?
1. Change the date on the hospital room whiteboard to yesterday's date.
2. Perform neurological assessment and assess pupillary response.
3. Administer Valium 40 mg IV since the client is about to have a seizure.
4. Call the family to see if the wedding can be repeated - answer ✔✔-2. Perform neurological
assessment and assess pupillary response.
The nurse needs to perform a neuro assessment to determine pupillary response, ask if a headache is
present, take vital signs, and contact the health care provider. The client may be exhibiting subtle signs
of increased intracranial pressure which includes restlessness, agitation, headache, and pupil changes.
A client is taking felbamate (Felbatol) for seizures and displays symptoms of pancytopenia based on
which assessment findings? (Select all that apply)
1. Sore throat
2. Epistaxis
3. Skin rash
4. Gingival hyperplasia - answer ✔✔-1. Sore throat
2. Epistaxis
,Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-like feeling, and may
exhibit increased bleeding with reduced platelet count (epitaxis). Skin rash may not indicate
pancytopenia. Gingival hyperplasia is an adverse affect of anticonvulsants like phenytoin, but is not a
symptom of pancytopenia. Pancytopenia affects red cells, white cells, and platelets and represents bone
marrow's response to on-hematologic conditions such as drugs.
A client is being discharged with a new prescription of phenytoin sodium (dilantin). Which instruction by
the nurse is most important to include?
1. If stopped abruptly, status epilepticus may occur.
2. Sulfonamides like Bactrim will decrease phenytoin levels in the blood.
3. Take the medication with antacids to reduce gastric upset.
4. Dilantin will not affect contraceptive effectiveness. - answer ✔✔-1. If stopped abruptly, status
epilepticus may occur.
It is important to instruct not to suddenly stop taking phenytoin sodium (Dilantin) as doing so may
present a risk for return of life-threatening seizure activity. Sulfonamides will increase phenytoin levels.
The drug should not be taken with antacids and will lower phenytoin absorption. Clients on
contraceptive hormone therapy may need to use alternative forms of non-hormonal contraceptives
while on phenytoin sodium (Dilantin).
The nurse is caring for a client who is unconscious who requires enteral feedings through a nasogastric
tube. Which action takes priority when managing enteral feedings?
1. Weigh the client daily at the same time.
2. Make sure sterile water and sterile gavage system is changed every 24 hours.
3. Keep the client in semi-fowlers position.
4. Keep the formula warm by setting in hot water 30 minutes prior to administration. - answer ✔✔-3.
Keep the client in semi-fowlers position.
It is most important to maintain a semi-flowlers position with nasogastric feedings to prevent aspiration.
While daily weights may be important, protecting the airway and lungs from aspiration is more
important. Having sterile water and supplies are not necessary since the management is with clean not
, sterile procedure. The formula should be room temperature and should never be heated prior to
administration.
The nurse will collaborate with the interdisciplinary team on communication assist with a client with
expressive aphasia. The team decided on which intervention to help with communication?
1. Make sure all staff know to speak slowly and in short sentences.
2. Make sure all staff speak loudly for the client to hear.
3. Make sure all staff write on a clipboard for the client to read communication.
4. Make sure all staff assist the client with use of a picture board which is client driven. - answer ✔✔-4.
Make sure all staff assist the client with use of a picture board which is client driven.
Expressive aphasia clients may understand what is heard or written, but they may not be able to verbally
communicate their needs. A picture or communication board helps the client as the client can point to
or direct others towards objects on the board for wants and needs. Speaking loudly or slowly is not
therapeutic for communication and may diminish the client's dignity. Having staff to be the only ones to
write implies one-way communication that is staff-driven and not client-need driven. The focus is client-
centered care and the client should be encouraged to express needs and wants through therapeutic
means.
The nurse is caring for a client with increased intracranial pressure. Which respiratory pattern changes
will signal increased intracranial pressure?
1. Rapid, shallow respirations.
2. Nasal flaring.
3. Slow, irregular respirations.
4. Sudden increase in respiratory secretions - answer ✔✔-3. Slow, irregular respirations.
Respiratory changes associated with increased intracranial pressure are the result of deterioration of
neural control of respirations, which is controlled by the brain stem. Deterioration and pressure produce
irregular respiratory patterns. Nasal flaring and rapid shallow respirations are a sign of respiratory
distress which may not have root causes because of neurological changes.
COMPLETE UPGRADED ACCURATE
ANSWERS .100% ACCURATE
In planning for discharge planning for a client with bacterial meningitis, the nurse will be sure to include
which instruction?
1. Keep all family and visitors from visiting your room for protective isolation.
2. Make sure you eat high protein diet with plenty of fluids
3. Take all of the antibiotics until gone.
4. Incorporate regular exercise with an active range of motion. - answer ✔✔-3. Take all of the antibiotics
until gone.
The client should be instructed to complete all antibiotics until they are completely gone. Failure to
complete antibiotics may lead to re-infection and may spread causing endocarditis and other infections
in the body, especially if the bacteria were from streptococci. While the client may be in isolation while
in the hospital, family may not need to quarantine the client when at home. Some family members
receive prophylactic antibiotics, but will be ordered according to the bacterial strain and health care
provider (HCP) recommendations. It is important to eat a good diet, but the most important will be
taking prescribed antibiotics. While returning to exercise is important, gradual increase should be
performed, and the answer selection for exercise was not as important as prescribed antibiotics.
The nurse is assessing the central stimulus function of an unconscious client in the intensive care unit.
The nurse should plan to use which technique to test the client's central response to stimuli?
1. Supraorbital ridge pressure.
2. Sternal rub.
3. Pressure on the nail bed.
4. Calling out loudly close to the client's ear. - answer ✔✔-1. Supraorbital ridge pressure.
,Central stimulus is applied to cranial nerves not peripheral nerves. Supraorbital ridge pressure by
applying pressure on the orbital rim is indicated for central stimulus assessment. Sternal rub is usually
not indicated via best practices. Pressure on the nail bed represents testing painful stimuli for motor
testing on peripheral nerves. Calling out loudly is not an assessment technique for central stimulus
function. There are two anatomic locations for pain stimulus: centrally and peripherally. Central involves
trapezious pinch or supraorbital pressure whereas peripheral stimuli are applied to extremities.
Responses may infer damage to the brain or specific brain areas.
A client is admitted for observation following a motor vehicle accident that occurred on the way to the
client's daughter's wedding. The next morning, instead of asking about the wedding, the client tells the
nurse "I have to leave now since the wedding is in a few minutes." The client then becomes agitated
when the nurse re-orients and states the actual date (which is the day following the wedding). What
should the nurse do next?
1. Change the date on the hospital room whiteboard to yesterday's date.
2. Perform neurological assessment and assess pupillary response.
3. Administer Valium 40 mg IV since the client is about to have a seizure.
4. Call the family to see if the wedding can be repeated - answer ✔✔-2. Perform neurological
assessment and assess pupillary response.
The nurse needs to perform a neuro assessment to determine pupillary response, ask if a headache is
present, take vital signs, and contact the health care provider. The client may be exhibiting subtle signs
of increased intracranial pressure which includes restlessness, agitation, headache, and pupil changes.
A client is taking felbamate (Felbatol) for seizures and displays symptoms of pancytopenia based on
which assessment findings? (Select all that apply)
1. Sore throat
2. Epistaxis
3. Skin rash
4. Gingival hyperplasia - answer ✔✔-1. Sore throat
2. Epistaxis
,Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-like feeling, and may
exhibit increased bleeding with reduced platelet count (epitaxis). Skin rash may not indicate
pancytopenia. Gingival hyperplasia is an adverse affect of anticonvulsants like phenytoin, but is not a
symptom of pancytopenia. Pancytopenia affects red cells, white cells, and platelets and represents bone
marrow's response to on-hematologic conditions such as drugs.
A client is being discharged with a new prescription of phenytoin sodium (dilantin). Which instruction by
the nurse is most important to include?
1. If stopped abruptly, status epilepticus may occur.
2. Sulfonamides like Bactrim will decrease phenytoin levels in the blood.
3. Take the medication with antacids to reduce gastric upset.
4. Dilantin will not affect contraceptive effectiveness. - answer ✔✔-1. If stopped abruptly, status
epilepticus may occur.
It is important to instruct not to suddenly stop taking phenytoin sodium (Dilantin) as doing so may
present a risk for return of life-threatening seizure activity. Sulfonamides will increase phenytoin levels.
The drug should not be taken with antacids and will lower phenytoin absorption. Clients on
contraceptive hormone therapy may need to use alternative forms of non-hormonal contraceptives
while on phenytoin sodium (Dilantin).
The nurse is caring for a client who is unconscious who requires enteral feedings through a nasogastric
tube. Which action takes priority when managing enteral feedings?
1. Weigh the client daily at the same time.
2. Make sure sterile water and sterile gavage system is changed every 24 hours.
3. Keep the client in semi-fowlers position.
4. Keep the formula warm by setting in hot water 30 minutes prior to administration. - answer ✔✔-3.
Keep the client in semi-fowlers position.
It is most important to maintain a semi-flowlers position with nasogastric feedings to prevent aspiration.
While daily weights may be important, protecting the airway and lungs from aspiration is more
important. Having sterile water and supplies are not necessary since the management is with clean not
, sterile procedure. The formula should be room temperature and should never be heated prior to
administration.
The nurse will collaborate with the interdisciplinary team on communication assist with a client with
expressive aphasia. The team decided on which intervention to help with communication?
1. Make sure all staff know to speak slowly and in short sentences.
2. Make sure all staff speak loudly for the client to hear.
3. Make sure all staff write on a clipboard for the client to read communication.
4. Make sure all staff assist the client with use of a picture board which is client driven. - answer ✔✔-4.
Make sure all staff assist the client with use of a picture board which is client driven.
Expressive aphasia clients may understand what is heard or written, but they may not be able to verbally
communicate their needs. A picture or communication board helps the client as the client can point to
or direct others towards objects on the board for wants and needs. Speaking loudly or slowly is not
therapeutic for communication and may diminish the client's dignity. Having staff to be the only ones to
write implies one-way communication that is staff-driven and not client-need driven. The focus is client-
centered care and the client should be encouraged to express needs and wants through therapeutic
means.
The nurse is caring for a client with increased intracranial pressure. Which respiratory pattern changes
will signal increased intracranial pressure?
1. Rapid, shallow respirations.
2. Nasal flaring.
3. Slow, irregular respirations.
4. Sudden increase in respiratory secretions - answer ✔✔-3. Slow, irregular respirations.
Respiratory changes associated with increased intracranial pressure are the result of deterioration of
neural control of respirations, which is controlled by the brain stem. Deterioration and pressure produce
irregular respiratory patterns. Nasal flaring and rapid shallow respirations are a sign of respiratory
distress which may not have root causes because of neurological changes.
