Med Surg III Exam 3 | NSG 233 Med Surg III
Exam 3 | All Questions and Correct
Answers | Graded A+ | Verified Answers |
Newest Exam
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous
membranes and restlessness. The client has IV fluids running at 75 mL/hr. What
action by the nurse is best?
a. Assess the clients magnesium level.
b. Assess the clients sodium level.
c. Increase the rate of the IV infusion.
d. Provide oral care every hour. ---------CORRECT ANSWER-----------------B
Rationale: This client has manifestations of hypernatremia, which is a possible
complication after a craniotomy. The nurse should assess the clients serum
sodium level. Magnesium level is not related. The nurse does not independently
increase the rate of the IV infusion. Providing oral care is also a good option but
does not take priority over assessing laboratory results.
A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse
questions the use of the drug, saying the client does not have a seizure disorder.
What response by the nurse is best?
a. Increased pressure from the abscess can cause seizures.
b. Preventing febrile seizures with an abscess is important.
c. Seizures always occur in clients with brain abscesses.
,d. This drug is used to sedate the client with an abscess. ---------CORRECT
ANSWER-----------------A
Rationale: Brain abscesses can lead to seizures as a complication. The nurse
should explain this to the spouse. Phenytoin is not used to prevent febrile
seizures. Seizures are possible but do not always occur in clients with brain
abscesses. This drug is not used for sedation.
A nurse is providing community screening for risk factors associated with stroke.
Which client would the nurse identify as being at highest risk for a stroke?
a. A 27-year-old heavy cocaine user
b. A 30-year-old who drinks a beer a day
c. A 40-year-old who uses seasonal antihistamines
d. A 65-year-old who is active and on no medications ---------CORRECT ANSWER----
-------------A
Rationale: Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy
alcohol is also a risk factor, but one beer a day is not considered heavy drinking.
Antihistamines may contain phenylpropanolamine, which also increases risk for
stroke, but this client uses them seasonally and there is no information that
they are abused or used heavily. The 65-year-old has only age as a risk factor.
A client experiences impaired swallowing after a stroke and has worked with
speech-language pathology on eating. What nursing assessment best indicates
that a priority goal for this problem has been met?
a. Chooses preferred items from the menu
b. Eats 75% to 100% of all meals and snacks
c. Has clear lung sounds on auscultation
,d. Gains 2 pounds after 1 week ---------CORRECT ANSWER-----------------C
Rationale: Impaired swallowing can lead to aspiration, so the priority goal for
this problem is no aspiration. Clear lung sounds is the best indicator that
aspiration has not occurred. Choosing menu items is not related to this
problem. Eating meals does not indicate the client is not still aspirating. A
weight gain indicates improved nutrition but still does not show a lack of
aspiration.
A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm
Hg. Based on the clients cerebral perfusion pressure, what should the nurse
anticipate for this client?
a. Impending brain herniation
b. Poor prognosis and cognitive function
c. Probable complete recovery
d. Unable to tell from this information ---------CORRECT ANSWER-----------------B
Rationale: The cerebral perfusion pressure (CPP) is the intracranial pressure
subtracted from the mean arterial pressure: in this case, 60-20=40. For optimal
outcomes, CPP should be at least 70 mmHg. This client has very low CPP, which
will probably lead to a poorer prognosis with significant cognitive dysfunction
should the client survive. This data does not indicate impending brain herniation
or complete recovery.
A client has a traumatic brain injury. The nurse assesses the following: pulse
change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg,
and respiratory irregularities. What action by the nurse takes priority?
a. Call the provider or Rapid Response Team.
b. Increase the rate of the IV fluid administration.
, c. Notify respiratory therapy for a breathing treatment.
d. Prepare to give IV pain medication. ---------CORRECT ANSWER-----------------A
Rationale: These manifestations indicate Cushings syndrome, a potentially life-
threatening increase in intracranial pressure (ICP), which is an emergency.
Immediate medical attention is necessary, so the nurse notifies the provider or
the Rapid Response Team. Increasing fluids would increase the ICP. The client
does not need a breathing treatment or pain medication.
A nurse is caring for four clients in the neurologic/neurosurgical intensive care
unit. Which client should the nurse assess first?
a. Client who has been diagnosed with meningitis with a fever of 101 F (38.3 C)
b. Client who had a transient ischemic attack and is waiting for teaching on
clopidogrel (Plavix)
c. Client receiving tissue plasminogen activator (t-PA) who has a change in
respiratory pattern and rate
d. Client who is waiting for subarachnoid bolt insertion with the consent form
already signed ---------CORRECT ANSWER-----------------C
Rationale: The client receiving t-PA has a change in neurologic status while
receiving this fibrinolytic therapy. The nurse assesses this client first as he or she
may have an intracerebral bleed. The client with meningitis has expected
manifestations. The client waiting for discharge teaching is a lower priority. The
client waiting for surgery can be assessed quickly after the nurse sees the client
who is receiving t-PA, or the nurse could delegate checking on this client to
another nurse.
After a stroke, a client has ataxia. What intervention is most appropriate to
include on the clients plan of care?
Exam 3 | All Questions and Correct
Answers | Graded A+ | Verified Answers |
Newest Exam
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous
membranes and restlessness. The client has IV fluids running at 75 mL/hr. What
action by the nurse is best?
a. Assess the clients magnesium level.
b. Assess the clients sodium level.
c. Increase the rate of the IV infusion.
d. Provide oral care every hour. ---------CORRECT ANSWER-----------------B
Rationale: This client has manifestations of hypernatremia, which is a possible
complication after a craniotomy. The nurse should assess the clients serum
sodium level. Magnesium level is not related. The nurse does not independently
increase the rate of the IV infusion. Providing oral care is also a good option but
does not take priority over assessing laboratory results.
A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse
questions the use of the drug, saying the client does not have a seizure disorder.
What response by the nurse is best?
a. Increased pressure from the abscess can cause seizures.
b. Preventing febrile seizures with an abscess is important.
c. Seizures always occur in clients with brain abscesses.
,d. This drug is used to sedate the client with an abscess. ---------CORRECT
ANSWER-----------------A
Rationale: Brain abscesses can lead to seizures as a complication. The nurse
should explain this to the spouse. Phenytoin is not used to prevent febrile
seizures. Seizures are possible but do not always occur in clients with brain
abscesses. This drug is not used for sedation.
A nurse is providing community screening for risk factors associated with stroke.
Which client would the nurse identify as being at highest risk for a stroke?
a. A 27-year-old heavy cocaine user
b. A 30-year-old who drinks a beer a day
c. A 40-year-old who uses seasonal antihistamines
d. A 65-year-old who is active and on no medications ---------CORRECT ANSWER----
-------------A
Rationale: Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy
alcohol is also a risk factor, but one beer a day is not considered heavy drinking.
Antihistamines may contain phenylpropanolamine, which also increases risk for
stroke, but this client uses them seasonally and there is no information that
they are abused or used heavily. The 65-year-old has only age as a risk factor.
A client experiences impaired swallowing after a stroke and has worked with
speech-language pathology on eating. What nursing assessment best indicates
that a priority goal for this problem has been met?
a. Chooses preferred items from the menu
b. Eats 75% to 100% of all meals and snacks
c. Has clear lung sounds on auscultation
,d. Gains 2 pounds after 1 week ---------CORRECT ANSWER-----------------C
Rationale: Impaired swallowing can lead to aspiration, so the priority goal for
this problem is no aspiration. Clear lung sounds is the best indicator that
aspiration has not occurred. Choosing menu items is not related to this
problem. Eating meals does not indicate the client is not still aspirating. A
weight gain indicates improved nutrition but still does not show a lack of
aspiration.
A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm
Hg. Based on the clients cerebral perfusion pressure, what should the nurse
anticipate for this client?
a. Impending brain herniation
b. Poor prognosis and cognitive function
c. Probable complete recovery
d. Unable to tell from this information ---------CORRECT ANSWER-----------------B
Rationale: The cerebral perfusion pressure (CPP) is the intracranial pressure
subtracted from the mean arterial pressure: in this case, 60-20=40. For optimal
outcomes, CPP should be at least 70 mmHg. This client has very low CPP, which
will probably lead to a poorer prognosis with significant cognitive dysfunction
should the client survive. This data does not indicate impending brain herniation
or complete recovery.
A client has a traumatic brain injury. The nurse assesses the following: pulse
change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg,
and respiratory irregularities. What action by the nurse takes priority?
a. Call the provider or Rapid Response Team.
b. Increase the rate of the IV fluid administration.
, c. Notify respiratory therapy for a breathing treatment.
d. Prepare to give IV pain medication. ---------CORRECT ANSWER-----------------A
Rationale: These manifestations indicate Cushings syndrome, a potentially life-
threatening increase in intracranial pressure (ICP), which is an emergency.
Immediate medical attention is necessary, so the nurse notifies the provider or
the Rapid Response Team. Increasing fluids would increase the ICP. The client
does not need a breathing treatment or pain medication.
A nurse is caring for four clients in the neurologic/neurosurgical intensive care
unit. Which client should the nurse assess first?
a. Client who has been diagnosed with meningitis with a fever of 101 F (38.3 C)
b. Client who had a transient ischemic attack and is waiting for teaching on
clopidogrel (Plavix)
c. Client receiving tissue plasminogen activator (t-PA) who has a change in
respiratory pattern and rate
d. Client who is waiting for subarachnoid bolt insertion with the consent form
already signed ---------CORRECT ANSWER-----------------C
Rationale: The client receiving t-PA has a change in neurologic status while
receiving this fibrinolytic therapy. The nurse assesses this client first as he or she
may have an intracerebral bleed. The client with meningitis has expected
manifestations. The client waiting for discharge teaching is a lower priority. The
client waiting for surgery can be assessed quickly after the nurse sees the client
who is receiving t-PA, or the nurse could delegate checking on this client to
another nurse.
After a stroke, a client has ataxia. What intervention is most appropriate to
include on the clients plan of care?
