N3 Final Study Guide

1.A child care worker complains of flu-like symptoms. On further assessment, hepatitis is suspected. The nurse realizes that this individual is at risk for which type of hepatitis? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D ANS: 1 Hepatitis A virus (HAV) is spread through the fecal-oral route. Child care workers are at greater risk because of potentially poor hygiene practices. Child care workers are not at the same risk for contracting hepatitis B, C, or D. 2. An older male is diagnosed with cirrhosis of the liver. The nurse knows that the most likely cause of this problem is: being in the military. traveling to a foreign country. drinking excessive alcohol. eating bad food. ANS: 3 The destruction to the liver from alcohol often progresses from fatty liver to alcoholic hepatitis and culminates in alcoholic cirrhosis. Alcoholic cirrhosis accounts for a great number of individuals diagnosed with this disease. Cirrhosis is not associated with being in the military, traveling to a foreign country, or eating bad food. 3. When the liver is seriously damaged, ammonia levels can rise in the body. One of the treatments for this is: administering intravenous (IV) neomycin. giving vitamin K. MICHE 1 lOMoARcPSD| 3. giving lactulose. 4. starting the patient on insulin. ANS: 3 Lactulose is a laxative that works by pulling water into the stool. It also helps pull ammonia from the blood into the colon for expulsion. IV antibiotics do not reduce serum ammonia levels. Vitamin K controls bleeding, but it does not reduce ammonia levels. Insulin is not used to reduce ammonia levels. 4.A client is scheduled for a liver biopsy. The nurse realizes that the most important sign to assess for is: 1. infection. 2. bleeding. 3. pain. 4. nausea and vomiting. ANS: 2 After a liver biopsy, the client is monitored for bleeding or hemorrhage. Infection and pain are of concern, but they are not the most important signs to be monitored. Nausea and vomiting are not typically associated with a liver biopsy. 5. The nurse realizes that the organ which is a major site for metastases, harboring and growing cancerous cells that originated in some other part of the body, is the: 1. spleen. 2. gallbladder. 3. liver. 4. stomach. ANS: 3 In most developed countries, this secondary type of liver cancer is more common than cancer that originates in the liver itself. The spleen, gallbladder, and stomach are not major sites for metastases. lOMoARcPSD| 1. cirrhosis due to hepatitis C. 2. biliary atresia. 3. diabetes. 4. Crohns disease. Preicteric . Icteric . 6. A school age child is placed on a waiting list for a liver transplant. The nurse knows that the most common reason for children to need this type of transplant is because of: ANS: 2 Biliary atresia is the most common reason for children to have a liver transplant. Cirrhosis due to hepatitis C is the reason for most adults to have a transplant. Children do not typically need a liver transplant for diabetes or Crohns disease. 7. Because health care workers are at a greater risk of hepatitis B infection, it is recommended that all health care workers: 1. wash their hands often. 2. avoid foreign travel. 3. become vaccinated. 4. drink bottled water only. ANS: 3 Because of the risk of blood and body fluid exposure, it is recommended that all health care workers be vaccinated against hepatitis B virus. All health care workers should engage in frequent handwashing, but handwashing is not the primary mechanism to prevent the onset of hepatitis B. Avoiding foreign travel and drinking bottled water only will not reduce the risk of hepatitis B. 8. A client who usually smokes a pack of cigarettes a day tells the nurse that he cannot stand the smell of smoke. The nurse realizes that this client is in which phase of hepatitis? lOMoARcPSD| Hyperkalemia . Hypercalcemia . Hypernatremia . 3 Posticteric . 4 Recovery . ANS: 1 In the preicteric phase of hepatitis, some smokers will have an aversion to smoking as a first sign of the disease. Smoking is not affected with the icteric or posticteric phases of the disease. Recovery is not a phase of hepatitis. 9. A female client is surprised to learn that she has been diagnosed with hemochromatosis. Which of the following should the nurse respond to this client? 1 It doesnt affect people until they are in their 50s. . 2 I would ask the doctor if hes sure about the diagnosis. . 3 Females often do not experience the effects of the disease until menopause. . 4 All women have the disorder but not the symptoms. . ANS: 3 Women do not experience the effects of hemochromatosis until menopause when the regular loss of blood stops. This disorder is a genetic disorder and can affect individuals of all ages. The nurse should not doubt the physicians diagnosis. All women do not have this disorder. 10. A client is diagnosed with liver disease. Which of the following is one impact of this disorder on a clients fluid and electrolyte status? lOMoARcPSD| 4 Hyponatremia . ANS: 4 Liver disease effects the fluid and electrolyte status by causing ascites, edema, hypokalemia, hypocalcemia, and hyponatremia. Liver disease does not cause hyperkalemia, hypercalcemia, or hypernatremia. 11. The nurse, caring for a client recovering from the placement of a shunt to treat portal hypertension, should assess the client for which of the following complications associated with this surgery? 1 Myocardial infarction . 2 Pulmonary emboli . 3 Pulmonary edema . 4 Decreased peripheral . pulses ANS: 3 Complications after shunt surgery include the development of pulmonary edema. Myocardial infarction, pulmonary emboli, and decreased peripheral pulses are not complications associated with this type of surgery. 12. A client is diagnosed with macrovesicular fatty liver. Which of the following should the nurse instruct this client? Expect to develop jaundice. Avoid all alcohol. Increase exercise. Treatment includes antibiotic therapy. lOMoARcPSD| 1. Fluid restriction 2. Low-sodium diet 3. Increased exercise 4. Diuretic therapy 5. Pain medication 6. Bed rest ANS: 2 The client diagnosed with macrovesicular fatty liver should be instructed to avoid all alcohol. Jaundice is a symptom of microvesicular fatty liver. The client should be instructed to rest. Antibiotic therapy is not indicated for macrovesicular fatty liver. MULTIPLE RESPONSE 1.A client diagnosed with cirrhosis is experiencing the complication of ascites. Which of the following would be considered treatment for this complication? (Select all that apply.) ANS: 1, 2, 4 Ascites is the accumulation of fluid in the peritoneal cavity. Treatment strategies include fluid restriction (1000 to 1500 mL/day), low-sodium diet (200 to 500 mg/day), and diuretic therapy to remove the excessive fluid. Increased exercise, pain medication, and bed rest are not included as treatments for this complication. 2.A client is recovering from an endoscopic retrograde cholangiopancreatogram (ERCP). Which of the following should the nurse assess as possible complications from this procedure? (Select all that apply.) 1. Perforation of the stomach 2. Perforated duodenum 3. Pancreatitis 4. Aspiration of gastric contents 5. Anaphylactic reaction to the contrast dye lOMoARcPSD| 6. Perforated bladder ANS: 1, 2, 3, 4, 5 Potential complications of an ERCP are perforated stomach and duodenum, pancreatitis, anaphylactic reaction to the contrast diet, aspiration of gastric contents, and reaction to anesthesia. A perforated bladder is a possible complication from a paracentesis. 3.A client is demonstrating yellow pigmentation of the skin and sclera. Which of the following can be used to describe this clients symptoms? (Select all that apply.) 1 Jaundice . 2 Dyspepsia . 3 Icterus . 4 Sclerosis . 5 Kernicterus . 6 Cirrhosis . ANS: 1, 3, 5 Terms used to describe yellow pigmentation of the skin and sclera include jaundice, icterus, and kernicterus. Dyspepsia, sclerosis, and cirrhosis are not terms used to describe the yellow pigmentation of the skin and sclera. 4. The nurse is providing dietary instruction to a client diagnosed with Wilsons disease. Which of the following should be included in these instructions? (Select all that apply.) 1. Avoid liver. 2. Avoid shellfish. 3. Eat soy products. lOMoARcPSD| 4. Use avocados in salads. 5. Avoid nectarines. 6. Avoid mushrooms. ANS: 1, 2, 5, 6 Dietary instruction for a client diagnosed with Wilsons disease include reducing the intake of foods high in copper. This includes avoiding liver, shellfish, soy products, avocado, nectarines, and mushrooms. 5. A client is diagnosed with a disorder of the liver. The nurse realizes this client might experience which of the following? (Select all that apply.) 1. Low vitamin A levels 2. Increased bleeding 3. Poor digestion of fats 4. Insulin resistance 5. Elevated levels of vitamin E 6. Nerve damage ANS: 1, 2, 3, 4, 6 Effects of a liver disorder on a client are many. Some of the functions affected by this disorder include low levels of fat soluble vitamins, including A and E; poor synthesis of clotting factors, leading to increased bleeding; poor digestion of fats; insulin resistance; and nerve damage. 6.A client is diagnosed with portal hypertension. The nurse should assess the client for which of the following disorders associated with this diagnosis? (Select all that apply.) 1 Esophageal varices . 2 Splenomegaly . lOMoARcPSD| 3 Hemorrhoids . 4 Caput medusae . 5 Gastritis . 6 Gallstone formation . ANS: 1, 2, 3, 4 Portal hypertension can lead to the development of esophageal varices, splenomegaly, hemorrhoids, and caput medusae. Portal hypertension does not lead to gastritis or gallstone formation. lOMoARcPSD| Chapter 60Musculoskeletal Trauma: Nursing Management MULTIPLE CHOICE 1.A client tells the nurse that he has pain, swelling, fatigue, and numbness of his hands. The nurse should assess the client for which of the following occupations? 1. Retail store clerk 2. Lifeguard 3. Computer keyboard operator 4. Bus driver ANS: 3 Some occupations, sports, and tasks can create repetitive motion injuries or cumulative trauma. A computer keyboard operator is an occupation with a high incidence of overuse syndrome. 2.A client who plays baseball on the weekends is experiencing an arm injury. The nurse realizes this client needs to be evaluated for: 1. a rotator cuff tear. 2. lateral epicondylitis. 3. dislocation of the shoulder. 4. patellar tendinopathy. ANS: 1 A rotator cuff tear can be caused by extensive overhead movements found in sports and activities such baseball, softball, tennis, swimming, and volleyball. A dislocation of the shoulder is most commonly caused by a fall on an outstretched hand and arm. Lateral epicondylitis, or tennis elbow, is an overuse injury that involves the extensor/supinator muscles that attach to the distal humerus. Patellar tendinopathy, also known as jumpers knee, is seen in athletes who participate in activities that require a lot of jumping such as basketball. 3.A client, diagnosed with an ankle sprain, is prescribed ibuprofen to control pain and inflammation. What instruction should the client receive concerning this medication? 1 Bleeding is not a problem with this medication. . lOMoARcPSD| Calling physical therapy for a sling Checking capillary refill time Giving pain medication Starting discharge teaching 2 Take on an empty stomach to maximize its effect. . 3 Take with food to minimize gastrointestinal irritation. . 4 Wear sunscreen if outside to prevent a burn. . ANS: 3 Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs should be taken with food to minimize gastrointestinal irritation. Ibuprofen does not increase photosensitivity; however, bleeding can be a problem when taking ibuprofen. 4.A client, experiencing a fractured arm, asks the nurse why the splint is being applied. Which of the following should the nurse respond to this client? 1. It reduces the need for a cast. 2. It reduces bleeding, swelling and pain. 3. It prevents the need for surgery. 4. It immobilizes the muscles and joints. ANS: 2 Splinting of a fractured extremity minimizes bleeding, edema, and pain. Splinting does not reduce the need for a cast nor prevent the need for surgery. A cast immobilizes the muscles and joints. 5. A client has had a cast applied to immobilize a right ulnar fracture. Which of the following nursing interventions is most important? ANS: 2 lOMoARcPSD| Checking the capillary refill time determines that circulation is not compromised. The other options can be completed after ensuring that circulation to the site is still adequate. 6. A client with a right arm cast is experiencing signs of a serious complication. Which of the following would cause the nurse the most concern? 1 Capillary refill time less than 3 seconds . 2 Finger movement . 3 Itching under the cast . 4 Severe pain to the right arm continues after receiving pain medication . ANS: 4 Severe pain that continues after receiving pain medication would be considered as being disproportionate to the injury, can be a sign of compartment syndrome, and should be immediately reported. The other options are expected assessment findings for a client with a cast. 7. A client is unable to pass the chair raise test. The nurse realizes this client is experiencing: 1. carpal tunnel syndrome. 2. rotator cuff tear. 3. fractured arm. 4. lateral epicondylitis. ANS: 4 The chair raise test examines the clients ability to grip and lift. The client stands behind a chair and places the hands on the chair back. The client then attempts to raise the chair. If pain is experienced over the lateral elbows, lateral epicondylitis may be present. The chair raise test is not used to diagnose carpal tunnel syndrome, rotator cuff tear, or a fractured arm. 8. A client has been wearing a splint for carpal tunnel syndrome for 7 weeks. The nurse realizes that which of the following would be the next course of treatment for this client? 1. Surgery lOMoARcPSD| 2. Exercises 3. Corticosteroid injection 4. Casting ANS: 3 If after 2 to 7 weeks of conservative treatment the carpal tunnel syndrome symptoms do not improve, corticosteroid injection is recommended. Surgery is not recommended until after corticosteroid injections have been tried. Exercises are implemented with the use of the splint. Casting is not a treatment for carpal tunnel syndrome. 9. The nurse is planning care for a client recovering from a meniscal injury. Which of the following should be included as strategies to avoid future injuries? Avoid hamstring muscle . exercises. Stretch before and after exercise. . Wear similar shoes for all . activities. Avoid skiing. . ANS: 2 Strategies to prevent future meniscal injuries include having strong thigh and hamstring muscles; stretching before and after exercise; wearing shoes that fit and are appropriate for the activity; and when skiing, having bindings that release the skis with a fall. 10. A client with an ankle sprain is instructed to follow RICE. Which of the following should the nurse instruct the client regarding this process? Maintain your normal level of activity. Apply ice to the ankle once a day. Apply an elastic bandage to the site. Elevate the extremity every day for 20 to 30 minutes. lOMoARcPSD| ANS: 3 The nurse should instruct the client to use crutches to allow for the rest of the ankle joint and relieve pain; apply ice for 20 to 30 minutes 3 to 4 times a day; apply an elastic bandage to the site; and elevate the ankle for the first 48 hours after the injury. 11. The nurse is evaluating the effectiveness of care for a client recovering from an injured Achilles tendon. Which of the following would indicate that care has been effective? Client states steroid injections will be helpful to reduce the amount of pain. . Client plans to participate in rehabilitation for 5 to 6 months after the injury. . Client resumes sports activities as soon as possible. . Client uses heat to decrease the inflammation and swelling from the injury. . ANS: 2 Evidence that care has been effective for a client recovering from an injured Achilles tendon would be that the client plans to participate in rehabilitation for 5 to 6 months after the injury. Steroid injections are not used for this type of injury. Sports activities should be avoided until the injury has healed and rehabilitation is completed. Cryotherapy, not heat, is used to decrease the inflammation and swelling from the injury. 12. The nurse is instructing a client on ways to prevent the onset of stress fractures. Which of the following should be included in these instructions? 1. Avoid overtraining 2. Increase intensity of training 10% each day 3. Limit warm up exercises 4. Avoid shock absorbing footwear ANS: 1 Interventions to prevent the onset of stress fractures include: avoid overtraining; gradually increase the intensity of workouts by 10% each week; perform adequate warm up exercises; and use shock absorbing footwear and insoles. 13. The nurse suspects a client, recovering from hip replacement surgery, is experiencing an infection when which of the following is assessed? lOMoARcPSD| 1. Client using crutches to ambulate 2. Blood pressure 110/68 mmHg 3. Pain with movement 4. Foot intact to sensation and motion ANS: 3 Evidence of an infection in the joint of a client recovering from hip replacement surgery includes erythema, edema, drainage, and tenderness over the joint; persistent pain in the joint with movement; and narrowing of the joint space upon x-ray. Using crutches to ambulate would not indicate an infection in the operative site. A blood pressure of 110/68 mmHg is within normal limits. The foot being intact to sensation and motion would indicate the limb is receiving sufficient blood and oxygenation. MULTIPLE RESPONSE 1. The nurse is concerned that a client is demonstrating signs of compartment syndrome. Which of the following is considered a classical symptom of this disorder? (Select all that apply.) Pain . Paraplegia . Paresthesia . Pink . Pressure . Pulselessness . lOMoARcPSD| ANS: 1, 3, 5, 6 The classical symptoms of the six Ps of compartment syndrome are pain, paresthesia, paresis, pressure, pallor, and pulselessness. The pink color and paraplegia are not part of the classic Ps. 2. A client is diagnosed with a pathological fracture. For which of the following disease processes should the nurse assess the client? (Select all that apply.) 1. Cushings syndrome 2. Osteomalacia 3. Pagets disease 4. Heart failure 5. Diabetes mellitus 6. Chronic obstructive pulmonary disease ANS: 1, 2, 3 Causes of pathological fractures include Cushings syndrome, osteomalacia, and Pagets disease. Pathological fractures are not associated with heart failure, diabetes mellitus, or chronic obstructive pulmonary disease. 3. A client, recovering from a fractured pelvis, begins to have dyspnea and restlessness. The nurse is concerned that the client is experiencing a fat emboli when which of the following are assessed? (Select all that apply.) 1. Upper body petechiae 2. Cough 3. Protein in the urine 4. Seizures 5. Temperature 102F 6. Elevated blood glucose level ANS: 1, 4, 5 Symptoms of fat emboli include hypoxemia, mental status changes, petechiae, seizures, and a body temperature greater than 101.3F. Cough, protein in the urine, and elevated blood glucose level are not symptoms of fat emboli. lOMoARcPSD| 4. The nurse is assessing a client recovering from abdominal surgery for the development of a deep vein thrombosis. Which of the following would indicate that the client is experiencing this disorder? (Select all that apply.) 1. Pain and tenderness of the lower extremity 2. Red area on a limb that is warm to the touch 3. Unexplained dyspnea 4. Chest pain 5. Hemoptysis 6. Drop in blood pressure ANS: 1, 2, 3, 4, 5 The client may describe limb pain as aching, cramping, sharp, dull, severe, or mild. Tenderness and pain of the lower extremity and a red area that is warm to touch are also indications that the disorder is present. Other signs and symptoms include unexplained dyspnea, chest pain, and hemoptysis. A drop in blood pressure is not an indication for a deep vein thrombosis. 5. The nurse is planning care for a client recovering from an amputation. Which of the following should be included in this plan of care? (Select all that apply.) Provide pain medication 30 minutes before stump care. . Wash the stump daily with mild soap and warm water. . Allow the stump to dry open to the air for 10 minutes after washing. . Avoid massaging the stump. . Elevate the stump on a pillow. . Lie prone 10 to 20 minutes every day. . ANS: 1, 2, 3, 6 lOMoARcPSD| Care of the client recovering from an amputation includes providing pain medication 30 minutes before stump care; washing the stump daily with mild soap and warm water; allowing the stump to dry open to the air for 10 minutes after washing; massaging the stump daily; avoiding elevating the stump on a pillow to prevent contractures; and lying prone for 10 to 20 minutes every day to prevent contractures. lOMoARcPSD| Chapter 37Degenerative Neurological Dysfunction: Nursing Management MULTIPLE CHOICE 1.A client is diagnosed with a headache from a secondary cause. The nurse realizes this type of headache can be caused by: 1. a tumor. 2. tension. 3. a migraine. 4. cluster ANS: 1 Primary headaches are identified when no organic cause can be found. A tumor headache is caused by a tumor and is classified as a secondary headache. 2. The nurse should instruct a client diagnosed with migraine headaches to be careful not to overdose on acetaminophen (Tylenol). Which drug should the nurse tell the patient to avoid? 1. Aleve 2. Aspirin 3. Ibuprofen 4. Vicodin ANS: 4 Vicodin, although a narcotic analgesic, also contains acetaminophen (Tylenol). It is very easy to overdose on the acetaminophen (Tylenol) component, which can lead to kidney damage. Aleve does not contain acetaminophen (Tylenol). Aspirin and ibuprofen do not contain acetaminophen (Tylenol). 3. A client is diagnosed with seizures occurring because of hepatic encephalopathy. The nurse realizes that the cause for this clients seizures would be: 1. physiological. 2. iatrogenic. 3. idiopathic. 4. psychokinetic. lOMoARcPSD| ANS: 1 The three major causes for seizures are physiological, iatrogenic, and idiopathic. Physiological seizures include those that occur with an acquired metabolic disorder such as hepatic encephalopathy. Iatrogenic causes include new medications or drug or alcohol use. Idiopathic causes include fevers, fatigue, or strong emotions. Psychokinetic is not a cause for seizures. 4.A client tells the nurse that he sees flashing lights that occur prior to the onset of a seizure. Which of the following phases of a seizure is this client describing to the nurse? 1. Prodromal phase 2. Aural phase 3. Ictal phase 4. Postictal phase ANS: 2 In the aural phase a sensation or warning occurs, which the patient often remembers. This warning can be visual, auditory, gustatory, or visceral in nature. The prodromal phase of a seizure includes the signs or activity before the seizure such as a headache or feeling depressed. The ictal phase of a seizure is the actual seizure. The postictal phase is the period immediately following the seizure. 5. A client is experiencing a grand mal seizure. Which of the following should the nurse do during this seizure? 1 Protect the clients head. . 2 Leave the client alone. . 3 Give water to the client to avoid dehydration. . 4 Place a finger in the clients mouth to avoid swallowing the tongue. . ANS: 1 One of the most important interventions for a nurse to perform during a seizure is to protect the clients head from injury. Never give a client a drink during a seizure. Placing a finger in the clients mouth could be very dangerous to the client and the nurse. Do not leave the client unattended during a seizure lOMoARcPSD| 1. Oral 2. Intranasal 3. Rectal 4. Intramuscular take the medication every day as prescribed by the doctor. . eat a balanced diet. . get lots of exercise. . take naps during the day. . 6. A client is prescribed phenytoin (Dilantin) for a seizure disorder. Which of the following would indicate that the client is adhering to the medication schedule? 1. The client is sleepy. 2. The client is not experiencing seizures. 3. The client no longer has headaches. 4. The client is eating more food. ANS: 2 Phenytoin (Dilantin) is a medication to control seizures. The absence of seizures indicates that the client is adhering to the medication schedule. Sleepiness, lack of headaches, or improved appetite are not indications that the medication is being used as prescribed. 7. The nurse is unable to insert an intravenous access line into a client who is currently experiencing a seizure. Which of the following routes can the nurse use to provide medication to the client at this time? ANS: 2 For a client experiencing a seizure, oral medications and sharp objects can be dangerous and should not be used. Intranasally administered drugs are rapid and effective in treating a client experiencing an acute seizure. Intranasal delivery is more effective than rectal. 8. One of the most important things a nurse can teach a client about seizure control is to: lOMoARcPSD| 1. Brain tumor 2. Myasthenia gravis 3. Multiple sclerosis 4. Diabetes ANS: 1 Medication is effective only if it is taken as prescribed, and suddenly stopping the medication can trigger an increase in seizure activity. Diet and exercise are important to a healthy lifestyle but do little to control seizure activity. 9. The nurse is instructing a client newly diagnosed with multiple sclerosis (MS). To determine the effectiveness of his teaching, the nurse would expect the client to state: 1. It is best for me to be in a cold environment. 2. I should avoid taking a hot bath. 3. I should eat foods low in salt. 4. I should be better in a week. ANS: 2 The clinical manifestations of MS can be exacerbated by being in a hot, humid environment or by taking a hot bath. A cold environment and low-salt foods do not impact the symptoms of multiple sclerosis. If the client states that they will improve in a week, instruction has not been effective. 10. An adult female in her 30s complains of numbness and tingling in the hands, fatigue, loss of coordination, incontinence, nystagmus, and ataxia. Which of the following health problems do these symptoms suggest to the nurse? ANS: 3 Multiple sclerosis is more common in women of this age. These are symptoms, along with the age and sex of the patient, that are common to MS. These symptoms are not necessarily associated with a brain tumor. Weakness is the primary symptom associated with myasthenia gravis. Symptoms of diabetes include weight loss, blurred vision, excessive urination, thirst, and hunger. 11. For a client diagnosed with Parkinsons disease, which of the following might be contraindicated? 1. Performing range-of-motion exercises 2. Drinking bottled water 3. Instituting fall precautions lOMoARcPSD| 4. Taking naps ANS: 2 Some clients diagnosed with Parkinsons disease develop swallowing difficulties. Powders to thicken liquids and using an upright position will help with these difficulties. Clients diagnosed with Parkinsons disease will benefit from range-of-motion exercises and resting. The client diagnosed with Parkinsons disease should be placed on fall precautions. 12. A client diagnosed with Parkinsons disease is beginning medication therapy. The nurse realizes that the goal of treatment for Parkinsons disease is to: 1. improve sleep. 2. reduce appetite. 3. control tremor and rigidity. 4. reduce the need for joint replacement surgery. ANS: 3 The goal of pharmacologic treatment for the client diagnosed with Parkinsons disease is to control tremor and rigidity and to improve the clients ability to carry out the activities of daily living. Medications for Parkinsons disease are not provided to improve sleep, reduce appetite, or reduce the need for joint replacement surgery. 13. A client presents complaining of abnormal muscle weakness and fatigability. The physician suspects myasthenia gravis. Which drug can be used to test for this disease? 1. Pyridostigmine (Mestinon) 2. Neostigmine (Prostigmin) 3. Ambenonium (Mytelase) 4. Edrophonium (Tensilon) ANS: 4 Tensilon, a short-acting anticholinesterase agent, is the drug of choice for diagnosing myasthenia gravis. The clients response is a rapid improvement of manifestations within 15 to 30 seconds that last 5 minutes. The other medications are used to treat clients diagnosed with myasthenia gravis. MULTIPLE RESPONSE lOMoARcPSD| 1.A client is diagnosed with tonic-clonic seizures. Which are the characteristics of these types of seizures? (Select all that apply.) 1. Progressing through all of the seizure phases 2. Beginning before age 5 3. Lasting 2 to 3 minutes 4. Causing injury to the client 5. Occurring at any time, day or night 6. Being highly variable ANS: 1, 3, 4, 5, 6 Tonic-clonic seizures are the most common type of generalized seizure. The seizure will progress through all of the seizure phases and last 2 to 3 minutes. Because these seizures begin suddenly, there is an increased incidence of injury associated with them. These seizures can occur any time of the day or night, whether the client is awake or not. Seizure frequency is highly variable. 2. Which of the following nursing interventions would be appropriate for a client diagnosed with Alzheimers disease? (Select all that apply.) 1 Make changes to the room often to stimulate memory function. . 2 Assign simple tasks to be completed by the client. . 3 Assist the client with any needs associated with activities of daily living (ADLs). . 4 Have personal/familiar items around the client. . 5 Do complex games and puzzles to improve memory. . ANS: 2, 3, 4 lOMoARcPSD| Alzheimers disease progressively alters the clients ability to function in the normal ways of living. Personal and familiar items help to keep the client oriented, and simple tasks keep the client functioning at the highest levels as long as possible. 3. A client has been diagnosed with Parkinsons disease. Which of the following will the nurse most likely assess in this client? (Select all that apply.) 1. Tremor 2. Muscle rigidity 3. Akinesia 4. Mask-like face 5. Dysphagia 6. Reduced appetite ANS: 1, 2, 3, 4, 5 Signs and symptoms of Parkinsons disease include tremor, muscle rigidity, akinesia, mask-like face, and dysphagia. Reduced appetite is not a sign or symptom of Parkinsons disease. 4. The nurse is planning care for a client diagnosed with myasthenia gravis. Which of the following should be included in this clients plan of care? (Select all that apply.) 1. Monitor activities frequently and assist as needed. 2. Encourage progressive increase in activities. 3. Determine the best communication method. 4. Monitor weight. 5. Restrict fluids. 6. Instruct in energy conservation measures. ANS: 1, 3, 4, 6 Care for the client diagnosed with myasthenia gravis includes frequent monitoring of activities and assisting as needed, determining the best communication method, monitoring weight, and instructing in energy conservation methods. Encouraging a progressive increase in activities and restricting fluids are not appropriate interventions for a client diagnosed with myasthenia gravis. 5. The nurse is instructing a client and family regarding the diagnosis of amyotrophic lateral sclerosis. Which of the following should be included in this teaching? (Select all that apply.) lOMoARcPSD| 1. Intellectual decline 2. Weight loss 3. Decreased appetite 4. Reduced blood pressure 5. Nausea 6. Abnormal movements 1 The length of the curative treatment . 2 That exercise and physical therapy can help the patient maximize function . 3 The physical, emotional, and social aspects of the disease . 4 End-of-life issues . 5 The use of devices to prevent aspiration pneumonia . 6 The use of a speech therapist to aid with communication . ANS: 2, 3, 4, 5, 6 Currently, no cure for this disease exists. Because of the progressive, degenerative nature of the disease, the supportive and educative role of the nurse is important. End-of-life issues need to be discussed before an emergency situation occurs. Other topics of instruction should include the purpose of physical therapy and speech therapy; the use of devices to prevent aspiration; and the emotional and social aspects of the disease. 6. The nurse is caring for a client diagnosed with Huntingtons disease. Which of the following are considered hallmark clinical manifestations of this disorder? (Select all that apply.) ANS: 1, 6 The hallmark clinical manifestations of Huntingtons disease are intellectual decline and abnormal movements. Weight loss, decreased appetite, reduced blood pressure, and nausea are not clinical manifestations of this disorder. lOMoARcPSD| Chapter 34Assessment of Neurological Function MULTIPLE CHOICE 1.A client is scheduled for surgery to fuse the vertebra in the lumbar region of the spine. The nurse should instruct the client that the number of vertebra being affected by this surgery would be: 1. 7. 2. 12. 3. 5. 4. 4. ANS: 3 There are 5 vertebra in the lumbar spine region. This is what the nurse should instruct the client as being fused during the surgery. There are 7 cervical vertebra, 12 thoracic, and 4 coccygeal fused into one. 2.A client has sustained a cerebral injury that is applying pressure to the corpus callosum. The nurse realizes that which of the following might occur with this client? Temporary blindness . Temporary inability to talk . Temporary inability to walk . Temporary miscommunication between the sides of the brain . ANS: 4 The corpus callosum allows the two hemispheres of the brain to communicate. An injury to this area could cause the client to experience temporary miscommunication between the sides of the brain. Pressure on this region may or may not lead to temporary blindness, the inability to talk, or the inability to walk. 3.A client is recovering from an injury to the frontal lobe of the brain. The nurse realizes that which of the following will be affected by this injury? Higher intellectual functioning Visual perception lOMoARcPSD| 3. Coordination 4. Respiratory rate ANS: 1 The major function of the frontal lobe of the cerebral hemisphere is high-level cognitive activity. This is what will be affected in the client with an injury to the frontal lobe. Visual perception occurs in the occipital lobe. Coordination occurs from the cerebellum. Respiratory rate is controlled by the brainstem. 4.A client is recovering from a cerebral bleed which is placing pressure on the hypothalamus. Which of the following will the nurse most likely assess in this client? 1. Variations in body temperature 2. Blindness 3. Alteration in speech 4. Uncoordinated body movements ANS: 1 The hypothalamus regulates temperature of the body. Pressure from a cerebral bleed on the hypothalamus could cause variations in the clients body temperature. Pressure to the hypothalamus will not cause blindness, alterations in speech, or uncoordinated body movements. 5. A client recovering from a cerebral vascular accident is having difficulty remembering how to chew food. The nurse realizes that which of the following cranial nerves could be affected in this client? 1. IX 2. X 3. XI 4. V ANS: 4 Cranial nerve V or Trigeminal nerve has three branches. The mandibular branch innervates the muscles for chewing. Cranial nerve IX glossopharyngeal innervates the muscles of swallowing. Cranial nerve X innervates the gastrointestinal tract through parasympathetic tracts of the nerve. Cranial nerve XI innervates the muscles of the neck for movement. 6. When utilizing the Glasgow Coma Scale during an assessment, the nurse identifies that the client is making incomprehensible sounds. This assessment finding would be included in which part of the assessment? lOMoARcPSD| 1. Eye opening 2. Verbal response 3. Best motor response 4. Mentation ANS: 2 The assessment finding of incomprehensible sounds would be documented within the verbal response section of the Glasgow Coma Scale. Eye opening would assess if the client opens the eyes in response to stimuli. Best motor response would assess the stimuli needed to have the client move an extremity or body part. Mentation is not a category within the Glasgow Coma Scale. 7. A client tells the nurse that at first she did not like to exercise but over time has grown to enjoy it and her body lets her know when she has not done enough. The nurse realizes that the client is experiencing which of the following neurological reactions to exercise? 1. Reduction in serotonin 2. Reduction in acetylcholine 3. Increase in endorphins 4. Reduction in dopamine ANS: 3 In response to exercise, the body will release endorphins from the pituitary gland, thalamus, spinal cord, and hypothalamus. This neurotransmitter aids to inhibit pain. Exercise does not reduce serotonin, acetylcholine, or dopamine. 8. Which of the following techniques should the nurse use to assess a clients pupillary response to light? 1 Briefly shine a penlight into the clients eye by passing the light from the outer edge of the eye toward . the center of the eye. 2 Turn the room lights on and off quickly three times. . 3 Have the client close his eyes and then quickly open them. . 4 Shine the light in the center of the clients eyes for one minute then check them for movement. lOMoARcPSD| 1. Extension of the toes 2. Flexion of the toes 3. No movement of the toes 4. Spasming of the toes . ANS: 1 By briefly shining a penlight into the clients eye from the outer edge toward the center of the eye and checking for movement of the pupil, the nurse can tell if there may be brain damage or nerve damage. The other choices are not appropriate technique to assess a clients pupillary response to light. 9. After assessing a clients plantar reflex, the nurse documents that the finding was normal. Which of the following did the nurse assess in this client? ANS: 2 The normal response is flexion of the toes. Any other response could signify neural impairment. 10. A client is scheduled for a computed tomography scan of the brain. Which of the following should the nurse do in order to prepare this client for the diagnosed test? Shave the clients head. . Administer a sedative. . Check to see if the client is allergic to shellfish or iodine. . Immobilize the head before movement. . ANS: 3 A CT scan commonly uses contrast agents. These contrast agents often have iodine in them. The nurse should check to see if the client is allergic to iodine or shellfish. Shellfish also have iodine in them. The nurse does not need to shave the clients head, administer a sedative, or immobilize the head before movement. 11. A client is scheduled for a diagnostic test to assess the amount of electrical activity within each of the cerebral hemispheres. The nurse realizes that the diagnostic test this client will be having is a(n): 1. myelogram. lOMoARcPSD| 1. 4+ 2. 3+ 3. 2+ 4. 1+ 2. electroencephalogram. 3. transcranial Doppler sonogram. 4. electromyogram. ANS: 2 An electroencephalogram or EEG measures the electrical activity of the cerebral hemispheres. A myelogram is an invasive procedure used to visualize obstructions, compression, or herniated intervertebral discs. A transcranial Doppler sonogram measures the velocities of intracranial brain vessels. The electromyogram measures the electrical activity of the peripheral nerves. 12. The nurse is assessing a client recovering from a carotid endarterectomy. Which of the following cranial nerves should the nurse include in this assessment? 1. CN V 2. CN VI 3. CN X 4. CN XII ANS: 4 Cranial nerve XII is the hypoglossal nerve. A common cause of dysfunction of this nerve is a carotid endarterectomy. During the surgical procedure, the nerve can be stretched, causing temporary weakness, the nerve can become severed, causing permanent dysfunction. Cranial nerves V, VI, and X are not affected by a carotid endarterectomy. 13. The nurse assessed a clients deep tendon reflexes as being normal. Which of the following will the nurse document in the clients medical record? lOMoARcPSD| ANS: 3 A deep tendon reflex of normal would be documented 2+. A deep tendon reflex that is very brisk would be documented as 4+. A deep tendon reflex being more brisk than normal would be documented as 3+. A deep tendon reflex that is sluggish would be documented as 1+. MULTIPLE RESPONSE 1. During an assessment, the nurse determines that a client is experiencing sympathetic responses. Which of the following did the nurse assess in this client? (Select all that apply.) 1. Decreased heart rate 2. Increased bowel sounds 3. Dilated pupils 4. Increased heart rate 5. Increased blood pressure 6. Increased respiratory rate ANS: 3, 4, 5, 6 Assessment findings consistent with a sympathetic response include dilated pupils, increased heart rate, increased blood pressure, and increased respiratory rate. Assessment findings consistent with a parasympathetic response include decreased heart rate and increased bowel sounds. tools can the nurse use to do this assessment? (Select all that apply.) 1. Snellen chart 2. Penlight 3. Cotton wisp 4. Rosenbaum pocket screener 5. Sharp object 6. Newspaper ANS: 1, 4, 6 Visual acuity can be assessed by using a Snellen chart, the Rosenbaum pocket vision screener, or a newspaper. A penlight is not used to assess visual acuity. A cotton wisp is used to test for a corneal reflex. A sharp object can be used to assess cutaneous reflexes. lOMoARcPSD| 1. Diplopia 2. Ageusia 3. Hypogeusia 4. Dysgeusia 5. Dysphagia 6. Ataxia 3.A client is assessed as having a taste abnormality. Which of the following terms can the nurse use to describe this assessment finding during documentation? (Select all that apply.) ANS: 2, 3, 4 Taste abnormalities include ageusia, or the absence of the sense of taste; hypogeusia, or diminished taste sensitivity; and dysgeusia, or a disturbed sense of taste. Diplopia is blurred or double vision. Dysphagia is difficulty swallowing. Ataxia is a lack of muscle coordination. 4. The nurse determines that a client is experiencing an alteration in sensory functioning when which of the following are assessed? (Select all that apply.) 1. Anesthesia 2. Hypesthesia 3. Parasthesia 4. Dysesthesia 5. Hypergesia 6. Ataxia ANS: 1, 2, 3, 4, 5 Disorders of sensory functioning can cause a variety of symptoms. Anesthesia is the absence of touch sensation. Hypesthesia is a diminished sense of touch. Parasthesia is numbness, tingling, or prickling sensations. Dysesthesia is burning or tingling. Hypergesia is increased sensitivity to pain. Ataxia described uncoordinated muscle (motor) movements most often assessed during ambulation and is not a part of the assessment of sensory functioning. lOMoARcPSD| 5. The nurse is reviewing the results for a clients analysis of cerebrospinal fluid. Which of the following would be considered an abnormal finding? (Select all that apply.) 1. Opening pressure 40 mmHg 2. Cloudy 3. Elevated red blood cell count 4. Elevated white blood cell count 5. Glucose level 60 mg/dL 6. pH 7.35 ANS: 1, 2, 3, 4 Abnormal cerebrospinal fluid analysis findings include opening pressure 40 mmHg, which could indicate dehydration; cloudy in appearance would indicate an increase in white blood cells; elevated red blood cell count would indicate either a traumatic spinal tap or active bleeding; and elevated white blood cell count would indicate meningitis, tumors, or multiple sclerosis. Glucose level of 60 md/dL is a normal finding. Fluid pH of 7.35 is a normal finding. lOMoARcPSD| Chapter 24Coronary Artery Dysfunction: Nursing Management MULTIPLE CHOICE 1.A client is learning about cholesterol. The nurse explains that the good cholesterol transports plasma cholesterol away from plaques and to the liver for metabolism. This type of cholesterol is called: 1. high-density lipoprotein. 2. low-density lipoprotein. 3. very-high-density lipoprotein. 4. very-low-density lipoprotein. ANS: 1 High-density lipoprotein transports plasma cholesterol away from atherosclerotic plaques and to the liver for metabolism and excretion. Low-density lipoproteins, or bad cholesterol, are the main component of the atherosclerotic plaque. Very-low-density lipoproteins are considered more atherogenic and are more common in men and people with diabetes. 2. A client has a blood pressure of 124/78 mmHg and a triglyceride level of 160 mg/dL. Based on these results, the nurse knows that the client has: an optimal blood pressure and triglyceride level. . a prehypertensive blood pressure and an optimal triglyceride level. . a prehypertensive blood pressure and a borderline high triglyceride level. . stage I hypertension and a high triglyceride level. . ANS: 3 Prehypertensive blood pressure ranges systolically from 120 to 139 mmHg or diastolically from 80 to 90 mmHg. Stage I hypertension is systolic blood pressure (SBP) of 140 to 159 mmHg or a diastolic blood pressure (DBP) of 90 to 99 mmHg. Optimal triglyceride levels are less than 150 mg/dL. Triglyceride levels from 150 to 199 mg/dL are considered borderline high. Triglyceride levels at 200 to 499 mg/dL are considered high. 3. The nurse measures a clients blood pressure to be 158/92 mmHg. The nurse recognizes that this blood pressure is classified as: 1. normal. lOMoARcPSD| 2. prehypertension. 3. stage I hypertension. 4. stage II hypertension. ANS: 3 Normal blood pressure is SBP less than 120 mmHg and DBP less than 80 mmHg. A prehypertensive state is SBP of 120 to 139 mmHg or DBP of 80 to 90 mmHg. Stage I hypertension is SBP of 140 to 159 mmHg or DBP of 90 to 99 mmHg. Stage II hypertension is a SBP of 160 mmHg or higher or a DBP of 100 mmHg or higher. 4.A client is complaining of chest pain that occurs during exercise. This pain is relieved when the client rests. The nurse realizes that this client is experiencing which type of angina? 1. Prinzmetals variant angina 2. Silent angina 3. Stable angina 4. Unstable angina ANS: 3 Stable angina is precipitated by factors that increase oxygen demand or reduce oxygen supply. Chest pain occurs predictably with the same onset, duration, and intensity and is relieved when the precipitating factor is removed or with nitroglycerin. Unstable angina is typified by an increase in frequency, duration, and intensity of symptoms at lower levels of activity and even at rest. Prinzmetals variant angina is a coronary artery spasm. Silent angina can occur with no pain at all and is common in diabetic patients. 5. A client diagnosed with stable angina is undergoing a 12-lead electrocardiogram. Which of the following results is not expected? 1. ST segment depression 2. ST segment elevation 3. T-wave flattening 4. T-wave inversion ANS: 2 lOMoARcPSD| During an episode of angina, T-wave flattening or inversions and ST segment depression may be seen on the electrocardiogram due to subendocardial ischemia. ST segment elevation is seen with impending or acute myocardial infarction. 6. A client is scheduled for a cardiac angiogram. Which of the following should the nurse instruct the client about this diagnostic test? 1. It is noninvasive. 2. Contrast dye is injected. 3. Clients can move about after the procedure. 4. General anesthesia is used. ANS: 2 A cardiac angiogram is a procedure that visualizes the structures of the heart and vessels. This is an invasive procedure; however, it does not need general anesthesia. The client is awake during the procedure. A contrast dye is injected, and the client may feel a warm sensation. The client must maintain bed rest with the leg straight for up to 4 to 6 hours after the catheter is removed. 7. When planning the care of a client diagnosed with stable angina, which of the following would be considered a goal of treatment? Decrease in ischemia and episodes of angina Prevent myocardial infection Reduction of risk factors Reduction of stress by education ANS: 1 The primary goal for the treatment of stable angina is to improve the quality of life by decreasing episodes of angina and ischemia. The second goal is to increase the quantity of life by preventing progression to myocardial infarction and death. Reduction of risk factors and education are both parts of a treatment plan. PTS: 1 DIF: Apply REF: Planning and Implementation: Goals 8. A client is prescribed a beta-blocker for treatment of coronary artery disease. Which of the following is the client most likely going to be prescribed? 1. Amlodipine 2. Atenolol 3. Diltiazem hydrochloride