Exam 1 - NUR2755 / NUR 2755 (Latest 2023 / 2024): Multidimensional Care IV / MDC 4 - Rasmussen

NUR 2755 Multidimensional Care IV MDC4 Exam 1 A client had an embolic stroke and is h aving an echocardiogram. When the client asks why the provider ordered "a test on my heart," how will the nurse respond? a. Most of these types of blood clots come from the heart b. Some of the blood clots may have gone to your heart too c. We need to see if your heart is strong enough for therapy d. Your heart may have been damaged in the stroke too Correct Answer: a. Most of these types of blood clots come from the heart Rationale: An embolic stroke is caused when blood clots travel fr om one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate. As the result of a stroke, a client has difficulty discerning the position of his body without looking at it. In the nurses d ocumentation, which would best describe the clients liability to assess the spatial position of the body? a. Agnosia b. Proprioception c. Apraxia d. Sensation Correct Answer: b. Proprioception A client is having an epileptic episode and develops loss of consciousness, incontinence, and breathing cessation for 25 seconds, followed by a postictal state lasting 15 minutes. The nurse understands this client is suffering from which type of seizure activity? a. Atonic seizure a. Simple partial seizure b. Pseudoseizure c. Tonic -clonic seizure Correct Answer: c. Tonic clonic seizure A client arrives at the emergency department with new onset slurred speech and weakness. The nurse inquires about when the client was last seen as normal. What other assessme nt information is critical for the health care team to know before a "stroke alert" can be initiated? a. client's weight b. National Institutes of Health (NIH) stroke scale score c. Blood glucose level d. Vital signs Correct Answer: c. Blood glucose level A nurse is preparing to administer heparin 3,500 units subcutaneously every 12 hours. The amount available is heparin injection 5,000 units/mL. How many mL should the nurse administer per dose? (record answer to the tenth (one decimal place). Correct Answer: 0.7 A male client, age 69, is being evaluated by a neurologist for signs of muscle rigidity, masklike face (the area from the forehead to chin), and propulsive gait. The nurse interprets these findings a s potential indicators of which neurol ogical disorder? a. Multiple sclerosis b. Parkinson's disease c. Alzheimer's disease d. Epilepsy Correct Answer: b. Parkinson's disease Before undergoing a computed tomography (CT) scan with a contrast medium, the nurse assesses the client for which of the following potential complications? a. Assess that the client is not allergic to seafood or iodine. b. Determine the client's ability to change position frequently during the procedure. c. Evaluate the ability to maintain a safe distance from the cli ent to reduce the exposure to radiation. d. Confirm that the client has no metal objects such as an implant or a pacemaker. Correct Answer: a. Assess that the client is not allergic to seafood or iodine.