MSN 377 EXAM 4 Study Guide Questions And
Answers Verified 100% Correct
A nurse in an emergency department is caring for a client who
suddenly lost consciousness and fell in her home. the provider
determines that the client had an embolic stroke. Which of the
following medications should the nurse administer?
A. Tissue plasminogen activator
B. Recombinant factor VIII
C. Nitroglycerin
D. Lidocaine - ANSWER -A. tissue plasminogen activatior
a thrombolytic that should dissolve the clot that caused the stroke
A nurse is assessing a client who had a right hemispheric stoke.
Which of the following neurologic deficits should the nurse expect?
A. aphasia
B. right sided neglect
C. impulsive behavior
D. inability to read - ANSWER -C. impulsive behavior
the nurse should expect impulsive behavior, poor judgment, and lack
of awareness of neurologic deficits
,A nurse is assessing a client who is quadriplegic following a cervical
fracture at vertebral level C5. the client reports a throbbing headache
and nausea. the nurse notes facial drooping and a blood pressure of
220/110. Which of the following actions should the nurse take first?
A. administer hydralazine via IV bolus
B. loosen the clients clothing
C. empty the client's bladder
D. elevate the head of the client's bed - ANSWER -D. elevate the head
of the client's bed
indicate autonomic dysreflexia and they are at risk for possible
rupture of a cerebral vessel or increased intracranial pressure. The
first action the nurse should take is to move the client from supine to
an upright position which will result in rapid postural hypotension.
A nurse is caring for a patient who has a history of status epilepticus
and requires seizure precautions. Which of the following actions
should the nurse take?
A. assess hourly for a spike in blood pressure
B. keep the client on bed rest
C. keep a padded tongue blade at the bedside
D. establish IV access - ANSWER -D. establish IV access
The nurse should plan to establish IV access with a large-bore
catheter and administer 0.9% sodium chloride if seizures are
imminent. If the client is stable, the nurse should initiate a saline lock.
, A nurse is assessing a client who has a head injury following a motor
vehicle accident. The nurse should identify that which of the following
findings indicates increasing ICP?
A. restlessness
B. dizziness
C. hypotension
D. fever - ANSWER -A. restlessness
Behavioral changes, such as restlessness and irritability, are early
manifestations of increased intracranial pressure.
A nurse is caring for a client who has multiple sclerosis. Which of the
following findings should the nurse expect?
A. hypoactive deep tendon reflexes
B. ascending paralysis
C. intention tremors
D. increased lacrimation - ANSWER -C. intention tremors
Clients who have multiple sclerosis are at risk for motor dysfunction,
with intention tremors, poor coordination, and loss of balance.
A nurse is caring for a client who is recovering from a stroke and has
right sided homonymous hemianopsia. To help the client adapt to the
hemianopsia, the nurse should take which of the following actions?
A. check the clients cheek on his affected side after he eats to be sure
no food remains there
Answers Verified 100% Correct
A nurse in an emergency department is caring for a client who
suddenly lost consciousness and fell in her home. the provider
determines that the client had an embolic stroke. Which of the
following medications should the nurse administer?
A. Tissue plasminogen activator
B. Recombinant factor VIII
C. Nitroglycerin
D. Lidocaine - ANSWER -A. tissue plasminogen activatior
a thrombolytic that should dissolve the clot that caused the stroke
A nurse is assessing a client who had a right hemispheric stoke.
Which of the following neurologic deficits should the nurse expect?
A. aphasia
B. right sided neglect
C. impulsive behavior
D. inability to read - ANSWER -C. impulsive behavior
the nurse should expect impulsive behavior, poor judgment, and lack
of awareness of neurologic deficits
,A nurse is assessing a client who is quadriplegic following a cervical
fracture at vertebral level C5. the client reports a throbbing headache
and nausea. the nurse notes facial drooping and a blood pressure of
220/110. Which of the following actions should the nurse take first?
A. administer hydralazine via IV bolus
B. loosen the clients clothing
C. empty the client's bladder
D. elevate the head of the client's bed - ANSWER -D. elevate the head
of the client's bed
indicate autonomic dysreflexia and they are at risk for possible
rupture of a cerebral vessel or increased intracranial pressure. The
first action the nurse should take is to move the client from supine to
an upright position which will result in rapid postural hypotension.
A nurse is caring for a patient who has a history of status epilepticus
and requires seizure precautions. Which of the following actions
should the nurse take?
A. assess hourly for a spike in blood pressure
B. keep the client on bed rest
C. keep a padded tongue blade at the bedside
D. establish IV access - ANSWER -D. establish IV access
The nurse should plan to establish IV access with a large-bore
catheter and administer 0.9% sodium chloride if seizures are
imminent. If the client is stable, the nurse should initiate a saline lock.
, A nurse is assessing a client who has a head injury following a motor
vehicle accident. The nurse should identify that which of the following
findings indicates increasing ICP?
A. restlessness
B. dizziness
C. hypotension
D. fever - ANSWER -A. restlessness
Behavioral changes, such as restlessness and irritability, are early
manifestations of increased intracranial pressure.
A nurse is caring for a client who has multiple sclerosis. Which of the
following findings should the nurse expect?
A. hypoactive deep tendon reflexes
B. ascending paralysis
C. intention tremors
D. increased lacrimation - ANSWER -C. intention tremors
Clients who have multiple sclerosis are at risk for motor dysfunction,
with intention tremors, poor coordination, and loss of balance.
A nurse is caring for a client who is recovering from a stroke and has
right sided homonymous hemianopsia. To help the client adapt to the
hemianopsia, the nurse should take which of the following actions?
A. check the clients cheek on his affected side after he eats to be sure
no food remains there
