CAPSTONE EXAM #3 QUESTIONS WITH
CORRECT ANSWERS
The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan
of care the nurse identifies seizure precautions and documents which items need to be
placed at the child's bedside? - Answer-Suctioning equipment and oxygen
A nurse is providing discharge teaching to parents whose infant had a
ventriculoperitoneal shunt placement for the treatment of hydrocephalus. Which of the
following statements by the parents indicates an understanding of the teaching? -
Answer-"We will notify the doctor right away if he has a fever."
Important to communicate to the surgeon after ventriculoperitoneal shunt is placed?3-
year-old returned ped unit - Answer-The right pupil is 1mm larger than the left pupil
A 27-year-old patient is hospitalized with new onset of Guillain-Barre syndrome. The
most essential assessment for the nurse to - Answer-carry out is observing respiratory
rate and effort.
The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The
client has complaints of inability to move both legs and reports a tingling sensation
above the waistline. Knowing the complications of the disorder the nurse should bring
which most essential items into the client's room? - Answer-Electrocardiographic
monitoring electrodes and intubation tray
A client with Guillain-Barre syndrome has ascending paralysis and is intubated and
recovering mechanical ventilation. Which strategy should the nurse incorporate in the
plan of care to help the client cope with this illness? - Answer-Providing information,
giving positive feedback, and encouraging relaxation
The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Which
past medical history finding makes the client most at risk for this disease? - Answer-
Respiratory or gastrointestinal infection during the previous month
The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's
sign. Which finding did the nurse observe? - Answer-The client passively flexes the hip
and knee in response to neck flexion and reports pain in the vertebral column.
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which
assessment finding would indicate that the client is developing meningitis as a
complication of surgery? - Answer-A positive Brudzinski's sign
, The nurse notes documentation that a child is exhibiting an inability to flex leg when the
thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? - Answer-
Meningitis
A lumbar puncture is performed on a child suspected to have bacterial meningitis and
cerebrospinal fluid is obtained for analysis. The nurse reviews the results of the CSF
analysis and determines which results would verify the diagnosis? - Answer-Cloudy
CSF, elevated protein, and decrease glucose levels
The nurse is planning care for a child with acute bacterial meningitis. Based on the
mode of transmission of this infection which precautionary intervention should be
included in the plan of care? - Answer-Maintain respiratory isolation precautions for at
least 24hrs after the initiation of antibiotics
Stroke (on the right side of the brain what would you see? Answers with the left side of
the body) - Answer-Left sided neglect, paralyzed left side, hemiplegia
The nurse is assigned to care for a client with complete right-sided hemiparesis from
stroke (brain attack). Which characteristics are associated with this condition? (SATA) -
Answer-The client is aphasic, The client has weakness on the right side of the body,
and The client has weakness on the right side of the face and tongue
When caring for a patient with a new right-sided homonymous hemianopsia resulting
from a stroke which intervention should the nurse include in the plan of care? - Answer-
Place objects needed on the patients left side.
A 73-year-old patient with a stroke experiences facial drooping on the right side and
right-sided arm and leg paralysis. When admitting the patient which clinical
manifestation will the nurse expect to find? - Answer-Difficulty comprehending
instructions
Risk factors for stroke (SATA) - Answer-High blood pressure, ischaemic attack,
Smoking -Use of oral contraceptives
The nurse is assessing the adaptation of a client to changes in functional status after a
stroke. Which observation indicates to the nurse that the client is adapting most
successfully? - Answer-Consistently uses adaptive equipment in dressing self
The nurse is teaching a client with Myasthenia Gravis about the prevention of
Myasthenic and cholinergic crisis. Which client activity suggests that teaching is most
effective? - Answer-Taking medications as scheduled
A client with Myasthenia Gravis has become increasingly weaker. The primary health
care provider prepares to identify whether the client is reacting to an overdose of the
medication (cholinergic crisis) or an increasing severity of the disease (myasthenic
CORRECT ANSWERS
The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan
of care the nurse identifies seizure precautions and documents which items need to be
placed at the child's bedside? - Answer-Suctioning equipment and oxygen
A nurse is providing discharge teaching to parents whose infant had a
ventriculoperitoneal shunt placement for the treatment of hydrocephalus. Which of the
following statements by the parents indicates an understanding of the teaching? -
Answer-"We will notify the doctor right away if he has a fever."
Important to communicate to the surgeon after ventriculoperitoneal shunt is placed?3-
year-old returned ped unit - Answer-The right pupil is 1mm larger than the left pupil
A 27-year-old patient is hospitalized with new onset of Guillain-Barre syndrome. The
most essential assessment for the nurse to - Answer-carry out is observing respiratory
rate and effort.
The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The
client has complaints of inability to move both legs and reports a tingling sensation
above the waistline. Knowing the complications of the disorder the nurse should bring
which most essential items into the client's room? - Answer-Electrocardiographic
monitoring electrodes and intubation tray
A client with Guillain-Barre syndrome has ascending paralysis and is intubated and
recovering mechanical ventilation. Which strategy should the nurse incorporate in the
plan of care to help the client cope with this illness? - Answer-Providing information,
giving positive feedback, and encouraging relaxation
The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Which
past medical history finding makes the client most at risk for this disease? - Answer-
Respiratory or gastrointestinal infection during the previous month
The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's
sign. Which finding did the nurse observe? - Answer-The client passively flexes the hip
and knee in response to neck flexion and reports pain in the vertebral column.
The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which
assessment finding would indicate that the client is developing meningitis as a
complication of surgery? - Answer-A positive Brudzinski's sign
, The nurse notes documentation that a child is exhibiting an inability to flex leg when the
thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? - Answer-
Meningitis
A lumbar puncture is performed on a child suspected to have bacterial meningitis and
cerebrospinal fluid is obtained for analysis. The nurse reviews the results of the CSF
analysis and determines which results would verify the diagnosis? - Answer-Cloudy
CSF, elevated protein, and decrease glucose levels
The nurse is planning care for a child with acute bacterial meningitis. Based on the
mode of transmission of this infection which precautionary intervention should be
included in the plan of care? - Answer-Maintain respiratory isolation precautions for at
least 24hrs after the initiation of antibiotics
Stroke (on the right side of the brain what would you see? Answers with the left side of
the body) - Answer-Left sided neglect, paralyzed left side, hemiplegia
The nurse is assigned to care for a client with complete right-sided hemiparesis from
stroke (brain attack). Which characteristics are associated with this condition? (SATA) -
Answer-The client is aphasic, The client has weakness on the right side of the body,
and The client has weakness on the right side of the face and tongue
When caring for a patient with a new right-sided homonymous hemianopsia resulting
from a stroke which intervention should the nurse include in the plan of care? - Answer-
Place objects needed on the patients left side.
A 73-year-old patient with a stroke experiences facial drooping on the right side and
right-sided arm and leg paralysis. When admitting the patient which clinical
manifestation will the nurse expect to find? - Answer-Difficulty comprehending
instructions
Risk factors for stroke (SATA) - Answer-High blood pressure, ischaemic attack,
Smoking -Use of oral contraceptives
The nurse is assessing the adaptation of a client to changes in functional status after a
stroke. Which observation indicates to the nurse that the client is adapting most
successfully? - Answer-Consistently uses adaptive equipment in dressing self
The nurse is teaching a client with Myasthenia Gravis about the prevention of
Myasthenic and cholinergic crisis. Which client activity suggests that teaching is most
effective? - Answer-Taking medications as scheduled
A client with Myasthenia Gravis has become increasingly weaker. The primary health
care provider prepares to identify whether the client is reacting to an overdose of the
medication (cholinergic crisis) or an increasing severity of the disease (myasthenic
