MED SURG NCLEX FINAL EXAM TEST BANK LATEST ACTUAL EXAM QUESTIONS

med surg nclex 1/4 A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. Which question is a priority for the nurse to ask this client or her family on admission? "Does the client have her own teeth or dentures?" take aspirin and if so, how much?" take nitroglycerin?" take digitalis?" ANSWER: take digitalis?" Elderly persons are particularly susceptible to digitalis intoxication (D) which manifests itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Although it is important to obtain a complete medication history (B and C), the symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly. (A) is irrelevant. The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question should provide information relevant to the client's plan of care? Have you ever experienced any paralysis of your arms or legs? Have you ever sustained a severe head injury? Have you ever been 'frozen' in one spot, unable to move? Do you have headaches, especially ones with throbbing pain? ANSWER: Have you ever been 'frozen' in one spot, unable to move? Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move (C). Parkinson's disease does not cause (A). Parkinson's disease is not usually associated with (B), nor does it typically cause (D). A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? Give 20 mEq of potassium chloride. Initiate continuous cardiac monitoring. Arrange a consultation with the dietician. Teach about the side effects of diuretics. ANSWER: Initiate continuous cardiac monitoring. . Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder? Describe proper administration of vaginal suppositories and cream. Encourage the client to perform Kegel exercises 10 times daily. Explain the importance of using condoms when having sexual intercourse. Discuss the importance of keeping a diary of daily temperature and menstrual cycle events. ANSWER: Encourage the client to perform Kegel exercises 10 times daily. Pelvic relaxation disorders are structural disorders resulting from weakening support tissues of the pelvis. (B) helps strengthen the surrounding muscles. Medication will not help correct a cystocele, rectocele, or uterine prolapse (A). (C) will help prevent sexually transmitted diseases. (D) is used to identify fertile times during the woman's menstrual cycle.