NUR480 EXAM 3 (LATEST UPDATE) REAL QUESTIONS AND
VERIFIED ANSWERS |100% CORRECT | ALREADY GRADED
A
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.
Ans✓✓✓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. Ans✓✓✓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 Ans✓✓✓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 Ans✓✓✓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. Ans✓✓✓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).
VERIFIED ANSWERS |100% CORRECT | ALREADY GRADED
A
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.
Ans✓✓✓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. Ans✓✓✓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 Ans✓✓✓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 Ans✓✓✓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. Ans✓✓✓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).
