NURS 405: Med Surg II Presentation NCLEX –
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Terms in this set (48)
A nurse is caring for a client who was A
recently admitted to the emergency
department following a head on MVA. Keep neck stabilized
Client is unresponsive, has
spontaneous respirations of 22/min, Rationale: the greatest risk to the client if permanent
and a laceration on his forehead that damage to the spinal cord if a cervical injury does
is bleeding. Which of the following is exist. The priority nursing intervention is to keep the
the priority nursing action at this time? neck immobile until damage to the cervical spine can
be ruled out
A) Keep neck stabilized
B) Insert NG tube
C) Monitor pulse and BP frequently
D) Establish IV access and start fluid
replacement
A client has experienced a left- C
hemispheric stroke, which of the
following would be an expected Inability to recognize familiar objects
finding?
Rationale: a client who experiences a left-
A) Impulse control difficulty hemispheric stroke will demonstrate the inability to
B) Poor judgement recognize familiar objects. This is also known as
C) Inability to recognize familiar agnosia
objects
D) Loss of depth perceptions
,A nurse is caring for a client who a B
spinal cord injury who reports a
severe headache and is sweating Sit the client upright in bed
profusely. BP is 220/110 with a heart
rate of 54/min. Which of the following Rationale: The greatest risk to the client is
actions should the nurse take first? experiencing a cerebrovascular accident (stroke)
secondary to elevated blood pressure. The first
A) Notify provider action by the nurse is to elevate the head of the bed
B) Sit the client upright in bed until the client is in an upright position. This will lower
C) Check the urinary catheter for the blood pressure secondary to postural
blockage hypotension.
D) Administer antihypertensive
medications
A client is admitted for treatment of C
the syndrome of inappropriate
antidiuretic hormone (SIADH). Which Restricting fluids
nursing intervention is appropriate?
Rationale: To reduce water retention in a client with
A) Infusing I.V. fluids rapidly as the SIADH, the nurse should restrict fluids.
ordered Administering fluids by any route would further
B) Encouraging increased oral intake increase the client's already heightened fluid load
C) Restricting fluids
D) Administering glucose-containing
I.V. fluids as ordered
A client with hypothyroidism C
(myxedema) is receiving levothyroxine
(Synthroid), 25 mcg P.O. daily. Which Tachycardia
finding should the nurse recognize as
an adverse effect? Rationale: Levothyroxine, a synthetic thyroid
hormone, is given to a client with hypothyroidism to
A) Dysuria simulate the effects of thyroxine. Adverse effects of
B) Leg cramps this agent include tachycardia. The other options
C) Tachycardia aren't associated with levothyroxine
D) Blurred vision
, Which outcome indicates that A
treatment of a client with diabetes
insipidus has been effective? Fluid intake is less than 2,500 ml/day.
A) Fluid intake is less than 2,500 Rationale: Diabetes insipidus is characterized by
ml/day. polyuria (up to 8 L/day), constant thirst, and an
B) Urine output measures more than unusually high oral intake of fluids. Treatment with the
200 ml/hour. appropriate drug should decrease both oral fluid
C) Blood pressure is 90/50 mm Hg. intake and urine output. A urine output of 200
D) The heart rate is 126 beats/minute. ml/hour indicates continuing polyuria. A blood
pressure of 90/50 mm Hg and a heart rate of 126
beats/minute indicate compensation for the
continued fluid deficit, suggesting that treatment
hasn't been effective
A client with Cushing's syndrome is A
admitted to the medical-surgical unit.
During the admission assessment, the Depression
nurse notes that the client is agitated
and irritable, has poor memory, Rationale: Agitation, irritability, poor memory, loss of
reports loss of appetite, and appears appetite, and neglect of one's appearance may signal
disheveled. These findings are depression, which is common in clients with Cushing's
consistent with which problem? syndrome. Neuropathy affects clients with diabetes
mellitus — not Cushing's syndrome. Although
A) Depression hypoglycemia can cause irritability, it also produces
B) Neuropathy increased appetite, rather than loss of appetite.
C) Hypoglycemia Hyperthyroidism typically causes such signs as
D) Hyperthyroidism goiter, nervousness, heat intolerance, and weight loss
despite increased appetite
Questions With Comprehensive Solutions
Save
Terms in this set (48)
A nurse is caring for a client who was A
recently admitted to the emergency
department following a head on MVA. Keep neck stabilized
Client is unresponsive, has
spontaneous respirations of 22/min, Rationale: the greatest risk to the client if permanent
and a laceration on his forehead that damage to the spinal cord if a cervical injury does
is bleeding. Which of the following is exist. The priority nursing intervention is to keep the
the priority nursing action at this time? neck immobile until damage to the cervical spine can
be ruled out
A) Keep neck stabilized
B) Insert NG tube
C) Monitor pulse and BP frequently
D) Establish IV access and start fluid
replacement
A client has experienced a left- C
hemispheric stroke, which of the
following would be an expected Inability to recognize familiar objects
finding?
Rationale: a client who experiences a left-
A) Impulse control difficulty hemispheric stroke will demonstrate the inability to
B) Poor judgement recognize familiar objects. This is also known as
C) Inability to recognize familiar agnosia
objects
D) Loss of depth perceptions
,A nurse is caring for a client who a B
spinal cord injury who reports a
severe headache and is sweating Sit the client upright in bed
profusely. BP is 220/110 with a heart
rate of 54/min. Which of the following Rationale: The greatest risk to the client is
actions should the nurse take first? experiencing a cerebrovascular accident (stroke)
secondary to elevated blood pressure. The first
A) Notify provider action by the nurse is to elevate the head of the bed
B) Sit the client upright in bed until the client is in an upright position. This will lower
C) Check the urinary catheter for the blood pressure secondary to postural
blockage hypotension.
D) Administer antihypertensive
medications
A client is admitted for treatment of C
the syndrome of inappropriate
antidiuretic hormone (SIADH). Which Restricting fluids
nursing intervention is appropriate?
Rationale: To reduce water retention in a client with
A) Infusing I.V. fluids rapidly as the SIADH, the nurse should restrict fluids.
ordered Administering fluids by any route would further
B) Encouraging increased oral intake increase the client's already heightened fluid load
C) Restricting fluids
D) Administering glucose-containing
I.V. fluids as ordered
A client with hypothyroidism C
(myxedema) is receiving levothyroxine
(Synthroid), 25 mcg P.O. daily. Which Tachycardia
finding should the nurse recognize as
an adverse effect? Rationale: Levothyroxine, a synthetic thyroid
hormone, is given to a client with hypothyroidism to
A) Dysuria simulate the effects of thyroxine. Adverse effects of
B) Leg cramps this agent include tachycardia. The other options
C) Tachycardia aren't associated with levothyroxine
D) Blurred vision
, Which outcome indicates that A
treatment of a client with diabetes
insipidus has been effective? Fluid intake is less than 2,500 ml/day.
A) Fluid intake is less than 2,500 Rationale: Diabetes insipidus is characterized by
ml/day. polyuria (up to 8 L/day), constant thirst, and an
B) Urine output measures more than unusually high oral intake of fluids. Treatment with the
200 ml/hour. appropriate drug should decrease both oral fluid
C) Blood pressure is 90/50 mm Hg. intake and urine output. A urine output of 200
D) The heart rate is 126 beats/minute. ml/hour indicates continuing polyuria. A blood
pressure of 90/50 mm Hg and a heart rate of 126
beats/minute indicate compensation for the
continued fluid deficit, suggesting that treatment
hasn't been effective
A client with Cushing's syndrome is A
admitted to the medical-surgical unit.
During the admission assessment, the Depression
nurse notes that the client is agitated
and irritable, has poor memory, Rationale: Agitation, irritability, poor memory, loss of
reports loss of appetite, and appears appetite, and neglect of one's appearance may signal
disheveled. These findings are depression, which is common in clients with Cushing's
consistent with which problem? syndrome. Neuropathy affects clients with diabetes
mellitus — not Cushing's syndrome. Although
A) Depression hypoglycemia can cause irritability, it also produces
B) Neuropathy increased appetite, rather than loss of appetite.
C) Hypoglycemia Hyperthyroidism typically causes such signs as
D) Hyperthyroidism goiter, nervousness, heat intolerance, and weight loss
despite increased appetite
