NUR 445 CLEAR, WELL-STRUCTURED AND REVISION-FRIENDLY NURSING EXAM GUIDE | OVER 200 QUESTIONS AND CORRECT ANSWERS GRADED A+

A client receiving alteplase (tPA) should not be prescribed anticoagulants like - Answer warfarin simultaneously, as this increases the risk of life-threatening hemorrhage. ischemic stroke, indicated - 12-lead ECG, bedside swallow testing, Monitoring electrolyte levels. Not indicated - - Answer maintaining systolic BP less than 120 mmHg, Keeping the client in a supine position, administration of TPA In hemorrhagic stroke, blood pressure control (target SBP <160 mmHg) and anticoagulation reversal are - Answer priorities. Aspirin and alteplase (tPA) are contraindicated, as they increase the risk of further bleeding. signs of a basilar skull fracture include - Answer clear nasal drainage suggestive of a cerebrospinal fluid (CSF) leak. Assessing cranial nerve function is also indicated A client is admitted with symptoms of an acute stroke. Upon assessment, the nurse notes that the client spontaneously opens their eyes, is confused when answering questions, and is unable to move their right arm but withdraws their left arm from pain. Using the Glasgow Coma Scale (GCS), how should the nurse document this client's assessment? - Answer 13 The nurse is assessing a client who sustained a severe head injury in a motor vehicle collision. The client opens their eyes only to painful stimuli, produces incomprehensible sounds, and withdraws from painful stimuli. Using the Glasgow Coma Scale (GCS), how should the nurse document this client's assessment? - Answer 8 The nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, uses inappropriate words in response to questions, and follows simple commands. Using the Glascow Coma Scale (GCS), how should the nurse document this client's assessment? - Answer 12 Remember that with all types of shock, except neuro, we have - Answer an elevated HR and low BP. What role do nurses play in caring for seriously ill patients and their families? - Answer Elicit goals of care Assess, manage, coordinate care Listen Bear witness Communicate with team Knowledgeable in evidence-based practice What are the top five leading causes of death in America? - Answer Heart disease Cancer Chronic lower respiratory disease Unintentional injury Cerebrovascular diseases What is the impact of serious illness in America on care? - Answer Exploding healthcare costs Poor understanding of prognosis Failure to treat pain and other symptoms Increased use of technology What constitutes quality of life care at end of life for the health care team? - Answer Providing symptom management and discussing the emotional aspects of the disease What constitutes quality care at the end of life for patients - Answer achieving a sense of control, attaining spiritual peace, succeeding in having finance in order, strengthening relationships with loved ones, and believing that their life has meaning ` T/F most adults prefer to die at home? - Answer True Nearly 40% of enrolled veterans live in _____________ communities - Answer Rural T/F the majority of veterans die in VA facilities - Answer False A client is hospitalized in ICU after a drug overdose. Which statement would the nurse interpret as indicating the client has normal mentation? (Select all that apply.) "Which part of the hospital am I in?" "I just want to die." "I should have swallowed the pills with bourbon." "Get that cat out of here." "My feet are cold." - Answer: 1, 2, 3, 5 A client reports feeling very anxious and not being able to sleep. The nurse anticipates initially administering a drug from which class to treat these disorders? Opiate narcotics Benzodiazepines Antidepressants Neuromuscular blockers - Answer: 2 Which characteristics would the nurse attribute to delirium rather than dementia? (Select all that apply.) The client's mentation was clear until he was hospitalized last week. The client does not recognize his children. The client has periods of clarity that alternate with confusion. The client's family reports his confusion has become steadily more pronounced over the last year The client continually tries to get out of bed stating, "I've got to get off this - Answer: 1, 3 A nurse is concerned that a hospitalized client may be developing delirium. Which interventions are indicated? (Select all that apply.) Ask the family to bring the client's eyeglasses from home. Turn room lights down at night to encourage sleep. Maintain bed rest until mentation improves. Remove the television from the room. Review the client's medication list. - Answer: 1, 2, 5 The nurse discovers a client having a seizure. What should be the nurse's initial action? Roll the client onto his or her side. Intubate the client immediately. Administer pentobarbital. Establish an IV line. - Answer: 1 A client experiencing continued seizure activity is to be given propofol. The nurse should prepare for which other intervention? Administration of insulin Mechanical ventilation Placement of an oral airway Administration of a neuromuscular blocking agent - Answer: 2 A client experienced an episode of vision loss and right-side weakness that lasted 4 hours before totally resolving. What information should the nurse provide to this client? "Your symptoms indicate that you have had a subarachnoid hemorrhage." "While these symptoms have resolved, your risk for a stroke is higher." "These symptoms often occur in older clients and are nothing to worry about." "Your stroke involved the occipital lobe and your vision will dim over the next few weeks." - Answer: 2 A client suffered a stroke yesterday and has recovered partial function. The client's spouse says, "I don't understand what is happening. When my mother had a stroke, she was left in a coma for years before she died." What is the nurse's best response? "All strokes are different." "Each client responds differently." "There are different levels of damage done by strokes." "Your mother must have had some additional medical problems." - Answer: 3 An 82-year-old African American man has a history of hypertension, type 1 diabetes, and had a stroke two years ago. He is a smoker and admits to leading a sedentary life style. The nurse analyzes this information to determine that the client has ________ non-modifiable risk factors for stroke. - 4: age, gender, ethnicity, and history of previous stroke. A nurse's neighbor calls and reports that her 64-year-old husband is complaining about loss of vision in one eye after mowing the lawn on a hot Sunday afternoon. He is awake and alert and says the vision loss came on slowly over about an hour. What advice should the nurse give? "Have him lie down and cool off and see if his vision is better." "Call his physician's answering service and ask them to relay the information to the doctor." "Give him a cold drink and I will be over as soon as I finish lunch to check on him." "Take him to urgent care or the emergency room." - Answer: 4 A patient who had a stroke has decreased level of consciousness, headache, and is vomiting. Using this information, which nursing diagnosis should the nurse assign? Impaired Skin Integrity Acute Pain Decreased Intracranial Adaptive Capacity Activity Intolerance - Answer: 3 A client is receiving an infusion of tPA for treatment of acute ischemic stroke. The nurse would immediately discontinue this infusion if the client manifested which assessment finding? (Select all that apply.) Nausea Severe headache Elevation of blood pressure to 180/100 Atrial fibrillation Decrease in pedal pulse amplitude - Answer: 1, 2, 3, 5 A client being treated for an ischemic stroke has vital signs of temperature: 39.0°C (102.2°F), blood pressure 160/90 mmHg, heart rate 98 bpm, and respirations 16 bpm. What action should the nurse take? (Select all that apply.) Continue to monitor Treat the temperature according to protocol STAT page the provider regarding the blood pressure Increase the client's oxygen delivery Accept these vital signs as normal for the client after ischemic stroke - Answer: 1, 2 The wife of a client who had a stroke says, "I'll never be able to care for him at home unless he can help me. When will therapy start to help him with walking?" Which answer, made by the nurse, is most appropriate? "Most stroke clients don't rebuild enough strength to help with their care." "The physical therapist will make that determination, and I'm certain they will talk with you about it then." "When he has some leg strength and balance back, we will start helping him learn to walk again." "As soon as his vital signs are stable, we will start walking therapy." - Answer: 3 A client was just admitted for treatment of stroke. Assessment reveals a well-nourished 63-year-old male with left-sided weakness, a weak gag reflex, and difficulty swallowing. The nurse would anticipate initiating nutritional support for this client if he is unable to take oral nourishment by which time? Within 24 hours of discontinuation of IV therapy Within 2 days of return of gag reflex Within 5 days of admission Within 12 hours of diagnosis - Answer: 3 The nurse is caring for a client who has right-sided weakness and Broca's aphasia following a stroke that occurred 36 hours ago. Which assessment instruction should the nurse use with this client? "Tell me what you were doing immediately before your illness." "Can you see anything at all out of your bad eye?" "Lift your unaffected arm up as much as you can." "Describe the sensations you have in your good leg." - Answer: 3 A client is admitted after being struck in the right side of the head with a baseball bat. An MRI shows the presence of focal injury and DAI. Which mechanism of injury is likely to have occurred? Acceleration Deceleration Rotational Penetrating - Answer: 3 A client was admitted to the emergency department after a traumatic brain injury. Current assessment included a decrease in Glasgow Coma Scale by one point and development of a fixed and dilated pupil. What should the nurse do first? Plan to reassess the client in 15 minutes. Call the healthcare provider immediately. Continue to prepare the client for an ordered CT scan. Inform the family of the status changes. - Answer: 2 A client fell on an icy sidewalk a week ago, striking the head on the curb. The CT scan reveals an accumulation of blood between the dura and the arachnoid covering of the brain. The nurse would prepare to care for a client with which diagnosis? Subdural hematoma Epidural hematoma Subarachnoid hematoma Intracerebral hematoma - Answer: 1 A client sustained a brain injury when struck by a falling tree limb. Upon admission to the emergency department (ED) the client's Glasgow Coma Score was 10. What interventions will the ED nurse expect to manage? (Select all that apply.) Explanation of brain injury surveillance as discharge instructions Skull x-rays CT scan Hospital admission Placement of an indwelling urinary catheter - Answer: 2, 3, 4 A client has an expanding epidural hematoma and is taken to the OR to have it evacuated. The client returns to the ICU ventilated and with an intraventricular catheter in place. According to Brain Trauma Foundation Guidelines, what is the minimal cerebral perfusion pressure (CPP) desired to reduce secondary injury in this client? 50 mm Hg 60 mm Hg 70 mm Hg 80 mm Hg - Answer: 2 A client who sustained a traumatic brain injury develops abrupt hypertension, bradycardia, and an irregular breathing pattern. The nurse immediately collaborates with the healthcare provider for which reason? The client needs additional pain medication. Anxiety is building that may cause additional problems. Herniation may be occurring. Brain death is occurring. - Answer: 3 The nurse should expect IV morphine to be prescribed first for a client with acute - Answer decompensated heart failure experiencing severe shortness of breath, tachypnea, tachycardia, and anxiety. Pacemaker and feeling dizzy -The nurse should first perform an electrocardiogram (ECG) to assess the pacemaker's function and determine if there are any issues with - Answer the pacemaker or the client's heart rhythm. Dizziness and nearfainting could be signs that the pacemaker is malfunctioning or that there is an issue with the heart rate. To increase the client's preload, the nurse should expect the health care provider to - Answer order a fluid bolus or resuscitation. Vasodilators/ nitroglycerin, nitroprusside) decrease - Answer systemic vascular resistance (SVR), reducing afterload and easing the workload on the heart. Cardiac output is dependent on heart rate and stroke volume. Positive inotropic medications/ dobutamine, dopamine) improve - Answer myocardial contractility, enhancing stroke volume and increasing cardiac output. In cardiogenic shock, the central venous pressure (CVP) is typically - Answer elevated, often in the range of 12-18 mmHg or higher Clients recovering from CABG surgery are at high risk for atelectasis and deconditioning due to prolonged bed rest and pain. Diminished breath sounds, tachypnea, and fatigue suggest - Answer impaired oxygenation and lung expansion. Early ambulation and deep breathing exercises help prevent respiratory complications and improve circulation. Heart failure- Placing the client in high Fowler's position is the first priority to reduce - Answer pulmonary congestion and improve oxygenation. After positioning, the nurse should administer IV furosemide to reduce fluid overload. The first step in the management of a snake bite is to - Answer clean the bite site gently with soap and water to reduce the risk of infection. An expanding hematoma and hypotension suggest an arterial bleed, a serious complication of - Answer cardiac catheterization. The priority is to apply firm pressure to the site to control bleeding The nurse should anticipate administering oral lactulose to reduce serum ammonia levels and improve mental status in a client with - Answer hepatic encephalopathy. Clients with liver failure are at risk for fluid retention and ascites, so a low-sodium diet is - Answer recommended. Protein should be moderated, but not completely avoided, as the body still requires it for muscle maintenance. In clients with cirrhosis and massive ascites, paracentesis is performed - Answer to remove excess fluid, relieve respiratory distress, and improve comfort. The most appropriate statement After a liver transplant is, - Answer "You will be on immunosuppressive therapy for the rest of your life." patients must take immunosuppressive medications to prevent organ rejection. After a liver biopsy, the client should lie on the right side for several hours to apply pressure to the biopsy site to - Answer prevent bleeding. Clients are usually NPO for a few hours before the procedure, not 24 hours. Light activity is typically allowed after the first day Clients with late-stage hepatitis are at risk for bleeding due to - Answer impaired liver function and decreased clotting factor production. Fresh frozen plasma (FFP) and vitamin K help improve clotting and reduce bleeding risk. ..