KeyGI/Neuro Med
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1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in
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supplying the client’s next container of TPN. Which of the following fluids should the nurse infuse until the next
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container arrives? ,f
A. Dextrose 5% in water ,f ,f ,f
Rationale: TPN contains high concentrations of certain nutrients. Infusing dextrose 5% in
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watercould cause rapid shifts in serum levels of some substances. ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f
B. 0.9% sodium chloride ,f ,f
Rationale: TPN contains high concentrations of certain nutrients. Infusing 0.9% ,f ,f ,f ,f ,f ,f ,f ,f ,f
sodiumchloride could cause rapid shifts in serum levels of some substances. ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f
,f C. , f Dextrose 10% in water ,f ,f ,f
Rationale: TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia,the
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nurse should infuse dextrose 10% or 20% in water until the next container of TPN ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f
solution arrives. ,f ,f
D. Lactated Ringer’s solution
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Rationale: TPN contains high concentrations of certain nutrients. Infusing lactated ,f ,f ,f ,f ,f ,f ,f ,f ,f
Ringer’ssolution could cause rapid shifts in serum levels of some substances. ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f
2. A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the
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followingstatements by the nurse is appropriate?
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A. “You should decrease your caloric intake when abdominal pain is present.”
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Rationale: Clients who have chronic pancreatitis are at risk for malnutrition and shouldincrease
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their caloric intake in order to maintain weight. ,f ,f ,f ,f ,f ,f ,f ,f
,f B. , f “You should increase your daily intake of protein.”
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Rationale: , f Clients who have chronic pancreatitis should consume a diet that is high in protein.
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C. “You should increase fat intake when experiencing loose stools.”
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Rationale: Clients who have chronic pancreatitis should consume a low-fat diet to ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f
preventstimulation of the pancreas and steatorrhea. ,f ,f ,f ,f ,f ,f ,f
D. “You should limit alcohol intake to 2-3 drinks per week.”
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Rationale: Clients who have chronic pancreatitis should avoid alcohol intake to preventstimulation
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of the pancreas. ,f ,f ,f
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3. A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If
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the client manifests increased intracranial pressure, which of the following findings should the nurse expect?
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(Select all that apply) ,f ,f ,f
,f A. , f Violent headache ,f
B. Neck pain and stiffness
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,f C. , f Slurred speech ,f
,f D. , f Projectile vomiting ,f
,f E. , f Rapid loss of consciousness ,f ,f ,f
Rationale: Violent headache is correct. The client who manifests ICP should display a
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violentheadache ,f ,f
Neck pain and stiffness is incorrect. The client who manifests ICP should
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notdisplay neck pain and stiffness
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Slurred speech is correct. The client who manifests ICP may display
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slurredspeech.
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Projectile vomiting is correct. The client who manifests ICP may display
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suddenonset of projectile vomiting.
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Rapid loss of consciousness is correct. The client who manifests ICP may display
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asudden rapid loss of consciousness.
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4. A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate
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finding by the nurse? ,f ,f ,f
,f A. , f Severe headache ,f
Rationale: The nurse should find as a sign of meningococcal meningitis severe headache dueto
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meningeal inflammation. ,f ,f
B. Bradycardia
Rationale: The nurse should find as a sign of meningococcal meningitis tachycardia
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notbradycardia. ,f ,f
C. Increased muscle tone ,f ,f
Rationale: The nurse should find as a sign of meningococcal meningitis decreased notincreased
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muscle tone. ,f ,f
D. Oriented to time, person, place ,f ,f ,f ,f
Rationale: The nurse should find as a sign of meningococcal meningitis disorientation
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notorientation to time, person, and place. ,f ,f ,f ,f ,f ,f ,f
5. A nurse admits a client who has a concussion for overnight observation. Alert and oriented on admission, the
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client reports a headache along with neck pain and generalized muscle aches. The nurse knows that a
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manifestation considered an early indication of increased intracranial pressure (ICP) is
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A. bradycardia.
Rationale: Alterations in vital signs, including increased systolic pressure, widening pulsepressure
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and bradycardia may be later signs of increased ICP. ,f ,f ,f ,f ,f ,f ,f ,f ,f
B. ipsilateral pupil dilation. ,f ,f
Rationale: Ipsilateral or bilateral pupil dilation occurs when increasing intracranial pressure
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displaces the brain against the optic nerve, but pupil dilation is not an early sign
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ofincreased ICP. ,f ,f ,f
C. widening pulse pressure. ,f ,f
Rationale: Alterations in vital signs, including increased systolic pressure, widening pulsepressure
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and bradycardia may be later signs of increased ICP. ,f ,f ,f ,f ,f ,f ,f ,f ,f
,f D. , f lethargy.
Rationale: Increased intracranial pressure is a condition in which the pressure of the
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cerebrospinal fluid or brain matter within the skull exceeds the upper limits
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fornormal. An early sign of increasing ICP is lethargy. ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f
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6. A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The
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nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?
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A. NPO until dysphagia subsides
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Rationale: Making the client NPO provides no nutritional support and will not likely beprescribed.
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,f B. , f Supplements via nasogastric tube ,f ,f ,f
Rationale: Supplements via nasogastric tube provide enteral nutrition for clients who are at riskfor
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aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f
therapy will likely be prescribed. ,f ,f ,f ,f ,f
C. Initiation of total parenteral nutrition
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Rationale: Total parenteral nutrition is initiated when the GI tract cannot be used for the ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f
ingestion, digestion, and absorption of essential nutrients. This nutritional ,f ,f ,f ,f ,f ,f ,f ,f ,f
therapywill not likely be prescribed. ,f ,f ,f ,f ,f ,f
D. Soft residue diet
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Rationale: A soft residue diet would place the client at risk for aspiration due to difficulty
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swallowing solids; therefore, this nutritional therapy will not likely be prescribed. ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f
7. A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she
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should communicate with the client. Which of the following is an appropriate response by the nurse?
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,f A. , f "Incorporate nonverbal cues in the conversation." ,f ,f ,f ,f ,f
Rationale: , f Nonverbal cues enhance the client’s ability to comprehend and use language. ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f
B. "Ask multiple choice questions as part of the conversation."
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Rationale: , f Simple questions requiring yes/no responses are better understood by the client.
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C. "Use a higher-pitched tone of voice when speaking." ,f ,f ,f ,f ,f ,f ,f
Rationale: Tone of voice is understood by clients with aphasia, unless they have a ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f ,f
hearingimpairment. ,f ,f
D. "Use simple child-like statements when speaking." ,f ,f ,f ,f ,f
Rationale: , f It is important to respect the client and use age-appropriate communication.
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