ngn or nclex uworld apr 28, apr 29, may 1-4, 6-7, 12 2023
Study online at https://quizlet.com/_d6w3lm
1. The nurse is planning for an 8-year-old client with mild cognitive impairment
who is hospitalized for Diagnostic testing. Which of the following interven-
tions are appropriate to include in the plan of care? Select all that apply
consistently a sign the same nurse and unlicensed assistive Personnel to care
for the client
give direct procedural education and explanations to the parent rather than
the client
provide appropriate toys based on developmental level rather than chrono-
logical age
reinforce parental limit setting measures for preventing self-injurious Behav-
ior
use a picture board to facilitate communication and promote understanding
of procedures: ANS 1345
Clients with cognitive impairment or intellectual disability are diagnosed prior to adulthood and have limited levels of
intellectual functioning and adaptive skills for their chronological age. manifestations may include decreased ability
to perform abstract or logical reasoning, interpret complex ideas, and learn by experience.
Cognitive impairment results in developmental delays of varying levels (e.g. mild, moderate) and types (e.g. cognitive,
physical, social, emotional, and Behavioral) and requires a nurse to assess the client's skills and abilities and provide
individualized care. appropriate nursing interventions for a client with cognitive impairment include:
promoting the staff's understanding of client Behavior needs and maintaining a familiar environment for the client
but consistently assigning the same staff for care (option 1)
fostering Play Time by providing toys that are developmentally appropriate, not necessarily age-appropriate (option
3)
preventing self injury by reinforcing the parents limit setting measures (eg time outs) and positively reinforcing good
behavior (option 4)
facilitating communication and learning by using visual demonstration (Eg picture board) rather than complex
explanations (option 5)
Option 2 the nurses involve parents and pre-procedural education but avoid excluding the client; explaining proce-
dures using methods appropriate for the client's cognitive abilities is encouraged.
educational objective appropriate nursing interventions when caring for a pediatric client with cognitive impairment
include providing consistency and staff assignments, providing toys appropriate for the client's developmental
, ngn or nclex uworld apr 28, apr 29, may 1-4, 6-7, 12 2023
Study online at https://quizlet.com/_d6w3lm
(not chronological) age, preventing self-injurious Behavior (eg reinforce parental limit setting) and using visual
demonstration (Eg picture board) and simple explanation to facilitate communication and learning.
2. A client with stroke symptoms has a blood pressure of 240/124 mmhg.
The nurse prepares the prescribed nicardipine intravenous infusion solution
correctly to yield 0.1mg/ml. The nurse then administers the initial prescription
to infuse at 5 mg/hr by setting the infusion pump at 50 ml/hr. What is the
nurse's priority action at this time?
assess hourly urinary output
increase pump setting to correct Administration rate 100 ml/hr
keeps systolic blood pressure above 170mmHg
monitor for a widening QT interval: ANS C
A client with an acute stroke presentation brain attack requires permissive hypertension during the first 24 to 48 hours
to allow for adequate perfusion through the damage cerebral tissues. however the blood-brain barriers are no longer
intact once the blood pressure is > 220/120 mmhg. Therefore, mild lowering is required usually to a systolic pressure
that is below 170 mmhg.
Nicardipine (Cardene) is its prototype of nifedipine and as a protein calcium channel blocking vasodilator. it takes
effect within one minute of IV Administration. It is essential to monitor the blood pressure is not being lowered too
quickly or too slowly as this would extend the stroke. hypertension can occur with or without reflex tachycardia. the
drug must be discontinued hypotension or reflex tachycardia occurs.
Option 1 it is important to watch for signs of adequate perfusion to the kidneys as indicated by adequate urine output.
Approximately 25% of the cardiac output goes to the kidney. However, the priority is to monitor for the rapid onset
of effect that this potent antihypertensive agent has after initiation. the nurse should wait until the year and output
drops.
Option 2 the initial rate set by the nurse is correct as desired dose/ dose on hand is 5mg/hr divided by 0.1mg/ml
and equals 50ml/hr.
Option 4 widening of the QT interval can increase the risk of life-threatening torsades de pointes. It is most commonly
seen with haloperidol (Haldol), methadone, ziprasidone (Geodon) and erythromycin. however this is not an expected
complication of Nicardipine.
3. The nurse is caring for a client after a motor vehicle collision. The client's
injuries include two fractured ribs and a concussion. Which of the following
are expected neurological changes for clients with a concussion? select all that
, ngn or nclex uworld apr 28, apr 29, may 1-4, 6-7, 12 2023
Study online at https://quizlet.com/_d6w3lm
apply
asymmetrical pupillary constriction
brief period of confusion
Headache
loss of vision
retrograde amnesia: ANS 235
A concussion is considered a minor traumatic brain injury that can result from blunt force trauma or acceleration/de-
celeration damage. Typical clinical manifestations of concussion include:
a brief period of confusion with or without loss of consciousness (option 2)
Headache (option 3)
Amnesia regarding events immediately preceding the head trauma (ie retrograde amnesia) option 5
Clients with the concussion should be observed closely by family members and should not participate in strenuous
or athletic activities for at least one to two days as long as symptoms have resolved. Rest in a light diet encouraged
during this time.
Options 1 and 4 asymmetrical pupillary constriction and vision loss would indicate a more serious brain injury. these
manifestations are not expected with the concussion
Educational objective:
expected neurological changes with the concussion include a brief period of confusion, headache, and retrograde
amnesia. these clients should be observed closely by family members and should not participate in strenuous or
athletic activities for at least one to two days as long as symptoms have resolved.
4. The nurse taught the caregiver of a client with a ventriculoperitoneal (VP)
shunt about when to contact the healthcare provider. The caregiver shows un-
derstanding of the instructions by contacting the hcp about which symptom?
A temperature of 99f or 37C that occurs during the evening
the child cannot recall items eaten for lunch the previous day
the child vomits after awakening from her nap and an hour later
the VP shunt is palpated along the posterior- lateral portion of the skull: ANS C
The caregiver of a child with a VP shunt must understand symptoms of increased intracranial pressure which indicates
shunt malfunction. Vomiting may be a sign of increased ICP and require the hcp be contacted.
Option 1 fever May indicate shunt infection but a temperature of 37° C remains with an acceptable parameters.
contacting the hcp is not indicated.
Option 2 memory laps or changes in mental status May indicate increased ICP. the inability to remember one meal
, ngn or nclex uworld apr 28, apr 29, may 1-4, 6-7, 12 2023
Study online at https://quizlet.com/_d6w3lm
will not indicate a change of mental status.
Option 4 a VP shunt is tunnel under the scalp and can be palpated
FYI
ventriculoperitoneal (VP) shunt Is placed connecting the ventricular space in the brain to the peritoneal cavity to drain.
Educational objective: increased ICP may occur with VP shunt malfunctions the caregiver must recognize symptoms
of vomiting, headaches, vision changes and changes in mental status. Early intervention by the hcp will decrease the
risk of damage to the brain tissue.
5. A client is being admitted for potential cerebellar pathology. Which tasks
should the nurse ask a client to perform to assess cerebellar function is within
the defined limits? Select all that apply
Identify the number '8' traced on the palm
shrug the shoulders against resistance
swallow water
touch each finger of one hand to the hand's thumb
walk Heel To Toe: ANS 45
The cerebellum is involved in two major functions: coronation of voluntary movements and maintenance of balance
and posture.
Maintenance of balance is assessed with gait testing and includes watching the clients normal gate first and then the
gate on Heel-To-Toe (tandem), on toes and on heels (option 5)
coordination testing involves the following:
finger tapping - ability to touch each finger of one hand to the hands thumb (option 4)
rapid alternating movements - rapid supination and pronation
finger to nose testing - clients touch the clinician's finger and then their own nose as a clinician's finger varies in
location
Heel to shin testing - client runs each heel down each Shin while in a Supine position
Option 1 this is a test of sensory function, especially fine touch (graphesthesia). other tests for this include identifying
an object in the hand (stereognosis) and two point discrimination
Option 2 shocking the shoulders against resistance ( as well as turning the head against resistance) is a test for cranial
nerve XI ( spinal accessory)
Option 3 in a client who has intact gag reflex, the ability to swallow water helps to assess CN IX (glossopharyngeal)
and CN X (vagus). the nurse can also observe for symmetrical rise of the soft palate and uvula by asking the client to
say 'ah'
Study online at https://quizlet.com/_d6w3lm
1. The nurse is planning for an 8-year-old client with mild cognitive impairment
who is hospitalized for Diagnostic testing. Which of the following interven-
tions are appropriate to include in the plan of care? Select all that apply
consistently a sign the same nurse and unlicensed assistive Personnel to care
for the client
give direct procedural education and explanations to the parent rather than
the client
provide appropriate toys based on developmental level rather than chrono-
logical age
reinforce parental limit setting measures for preventing self-injurious Behav-
ior
use a picture board to facilitate communication and promote understanding
of procedures: ANS 1345
Clients with cognitive impairment or intellectual disability are diagnosed prior to adulthood and have limited levels of
intellectual functioning and adaptive skills for their chronological age. manifestations may include decreased ability
to perform abstract or logical reasoning, interpret complex ideas, and learn by experience.
Cognitive impairment results in developmental delays of varying levels (e.g. mild, moderate) and types (e.g. cognitive,
physical, social, emotional, and Behavioral) and requires a nurse to assess the client's skills and abilities and provide
individualized care. appropriate nursing interventions for a client with cognitive impairment include:
promoting the staff's understanding of client Behavior needs and maintaining a familiar environment for the client
but consistently assigning the same staff for care (option 1)
fostering Play Time by providing toys that are developmentally appropriate, not necessarily age-appropriate (option
3)
preventing self injury by reinforcing the parents limit setting measures (eg time outs) and positively reinforcing good
behavior (option 4)
facilitating communication and learning by using visual demonstration (Eg picture board) rather than complex
explanations (option 5)
Option 2 the nurses involve parents and pre-procedural education but avoid excluding the client; explaining proce-
dures using methods appropriate for the client's cognitive abilities is encouraged.
educational objective appropriate nursing interventions when caring for a pediatric client with cognitive impairment
include providing consistency and staff assignments, providing toys appropriate for the client's developmental
, ngn or nclex uworld apr 28, apr 29, may 1-4, 6-7, 12 2023
Study online at https://quizlet.com/_d6w3lm
(not chronological) age, preventing self-injurious Behavior (eg reinforce parental limit setting) and using visual
demonstration (Eg picture board) and simple explanation to facilitate communication and learning.
2. A client with stroke symptoms has a blood pressure of 240/124 mmhg.
The nurse prepares the prescribed nicardipine intravenous infusion solution
correctly to yield 0.1mg/ml. The nurse then administers the initial prescription
to infuse at 5 mg/hr by setting the infusion pump at 50 ml/hr. What is the
nurse's priority action at this time?
assess hourly urinary output
increase pump setting to correct Administration rate 100 ml/hr
keeps systolic blood pressure above 170mmHg
monitor for a widening QT interval: ANS C
A client with an acute stroke presentation brain attack requires permissive hypertension during the first 24 to 48 hours
to allow for adequate perfusion through the damage cerebral tissues. however the blood-brain barriers are no longer
intact once the blood pressure is > 220/120 mmhg. Therefore, mild lowering is required usually to a systolic pressure
that is below 170 mmhg.
Nicardipine (Cardene) is its prototype of nifedipine and as a protein calcium channel blocking vasodilator. it takes
effect within one minute of IV Administration. It is essential to monitor the blood pressure is not being lowered too
quickly or too slowly as this would extend the stroke. hypertension can occur with or without reflex tachycardia. the
drug must be discontinued hypotension or reflex tachycardia occurs.
Option 1 it is important to watch for signs of adequate perfusion to the kidneys as indicated by adequate urine output.
Approximately 25% of the cardiac output goes to the kidney. However, the priority is to monitor for the rapid onset
of effect that this potent antihypertensive agent has after initiation. the nurse should wait until the year and output
drops.
Option 2 the initial rate set by the nurse is correct as desired dose/ dose on hand is 5mg/hr divided by 0.1mg/ml
and equals 50ml/hr.
Option 4 widening of the QT interval can increase the risk of life-threatening torsades de pointes. It is most commonly
seen with haloperidol (Haldol), methadone, ziprasidone (Geodon) and erythromycin. however this is not an expected
complication of Nicardipine.
3. The nurse is caring for a client after a motor vehicle collision. The client's
injuries include two fractured ribs and a concussion. Which of the following
are expected neurological changes for clients with a concussion? select all that
, ngn or nclex uworld apr 28, apr 29, may 1-4, 6-7, 12 2023
Study online at https://quizlet.com/_d6w3lm
apply
asymmetrical pupillary constriction
brief period of confusion
Headache
loss of vision
retrograde amnesia: ANS 235
A concussion is considered a minor traumatic brain injury that can result from blunt force trauma or acceleration/de-
celeration damage. Typical clinical manifestations of concussion include:
a brief period of confusion with or without loss of consciousness (option 2)
Headache (option 3)
Amnesia regarding events immediately preceding the head trauma (ie retrograde amnesia) option 5
Clients with the concussion should be observed closely by family members and should not participate in strenuous
or athletic activities for at least one to two days as long as symptoms have resolved. Rest in a light diet encouraged
during this time.
Options 1 and 4 asymmetrical pupillary constriction and vision loss would indicate a more serious brain injury. these
manifestations are not expected with the concussion
Educational objective:
expected neurological changes with the concussion include a brief period of confusion, headache, and retrograde
amnesia. these clients should be observed closely by family members and should not participate in strenuous or
athletic activities for at least one to two days as long as symptoms have resolved.
4. The nurse taught the caregiver of a client with a ventriculoperitoneal (VP)
shunt about when to contact the healthcare provider. The caregiver shows un-
derstanding of the instructions by contacting the hcp about which symptom?
A temperature of 99f or 37C that occurs during the evening
the child cannot recall items eaten for lunch the previous day
the child vomits after awakening from her nap and an hour later
the VP shunt is palpated along the posterior- lateral portion of the skull: ANS C
The caregiver of a child with a VP shunt must understand symptoms of increased intracranial pressure which indicates
shunt malfunction. Vomiting may be a sign of increased ICP and require the hcp be contacted.
Option 1 fever May indicate shunt infection but a temperature of 37° C remains with an acceptable parameters.
contacting the hcp is not indicated.
Option 2 memory laps or changes in mental status May indicate increased ICP. the inability to remember one meal
, ngn or nclex uworld apr 28, apr 29, may 1-4, 6-7, 12 2023
Study online at https://quizlet.com/_d6w3lm
will not indicate a change of mental status.
Option 4 a VP shunt is tunnel under the scalp and can be palpated
FYI
ventriculoperitoneal (VP) shunt Is placed connecting the ventricular space in the brain to the peritoneal cavity to drain.
Educational objective: increased ICP may occur with VP shunt malfunctions the caregiver must recognize symptoms
of vomiting, headaches, vision changes and changes in mental status. Early intervention by the hcp will decrease the
risk of damage to the brain tissue.
5. A client is being admitted for potential cerebellar pathology. Which tasks
should the nurse ask a client to perform to assess cerebellar function is within
the defined limits? Select all that apply
Identify the number '8' traced on the palm
shrug the shoulders against resistance
swallow water
touch each finger of one hand to the hand's thumb
walk Heel To Toe: ANS 45
The cerebellum is involved in two major functions: coronation of voluntary movements and maintenance of balance
and posture.
Maintenance of balance is assessed with gait testing and includes watching the clients normal gate first and then the
gate on Heel-To-Toe (tandem), on toes and on heels (option 5)
coordination testing involves the following:
finger tapping - ability to touch each finger of one hand to the hands thumb (option 4)
rapid alternating movements - rapid supination and pronation
finger to nose testing - clients touch the clinician's finger and then their own nose as a clinician's finger varies in
location
Heel to shin testing - client runs each heel down each Shin while in a Supine position
Option 1 this is a test of sensory function, especially fine touch (graphesthesia). other tests for this include identifying
an object in the hand (stereognosis) and two point discrimination
Option 2 shocking the shoulders against resistance ( as well as turning the head against resistance) is a test for cranial
nerve XI ( spinal accessory)
Option 3 in a client who has intact gag reflex, the ability to swallow water helps to assess CN IX (glossopharyngeal)
and CN X (vagus). the nurse can also observe for symmetrical rise of the soft palate and uvula by asking the client to
say 'ah'
