LACHARITY CH. 9 – NURSING/MEDICAL-SURGICAL PRACTICE
QUESTIONS WITH CORRECT ANSWERS {VERIFIED ANSWERS}
|ALREADY GRADED A+
The nurse is assessing a client with a neurologic health problem and discovers a
change in level of consciousness from alert to lethargic. What is the nurse's best
action?
1. Perform a complete neurologic assessment.
2. Assess the cranial nerve functions.
3. Contact the Rapid Response Team.
4. Reassess the client in 30 minutes. - ANSWER - 3
A change in level of consciousness and orientation is the earliest and most reliable
indication that central neurologic function has declined. If a decline occurs,
contact the Rapid Response Team or health care provider immediately. The nurse
should also perform a focused assessment to determine if there are any other
changes
The nurse on the neurologic acute care unit is assessing the orientation of a client
with severe headaches. Which questions would the nurse use to determine
orientation? Select all that apply.
1. When did you first experience the headache symptoms?
2. Who is the Mayor of Cleveland?
3. What is your health care provider's name?
4. What year and month is this?
5. What is your parents' address?
,6. What is the name of this health care facility? - ANSWER - 1, 3, 4, 6
After determining alertness in a client, the next step is to evaluate orientation.
When the client's attention is engaged, ask him or her questions to determine
orientation. Varying the sequence of questioning on repeated assessments
prevents the client from memorizing the answers. Responses that indicate
orientation include the ability to answer questions about person, place, and time
by asking for information such as the client's ability to relate the onset of
symptoms, the name of his or her health care provider or nurse, the year and
month, his or her address, and the name of the referring physician or health care
agency. Asking about mayors' names or parents' address may be inappropriate to
assess orientation.
What is the priority nursing concern for a client experiencing a migraine
headache?
1. Pain
2. Anxiety
3. Hopelessness
4. Risk for brain injury - ANSWER - 1
The priority for interdisciplinary care for the client experiencing a migraine
headache is pain management. All of the other problems are accurate, but none
of them is as urgent as the issue of pain, which is often incapacitating.
The nurse is creating a teaching plan for a client with newly diagnosed migraine
headaches. Which key items will be included in the teaching plan? Select all that
apply.
1. Foods that contain tyramine, such as alcohol and aged cheese, should be
avoided.
2. Drugs such as nitroglycerin and nifedipine should be avoided.
3. Abortive therapy is aimed at eliminating the pain during the aura.
, 4. A potential side effect of medications is rebound headache.
5. Complementary therapies such as biofeedback and relaxation may be helpful.
6. Estrogen therapy should be continued as prescribed by the client's health care
provider. - ANSWER - 1, 2, 3, 4, 5
Medications such as estrogen supplements may actually trigger a migraine
headache attack. All of the other statements are accurate and should be included
in the teaching plan.
After a client has a seizure, which action can the nurse delegate to the unlicensed
assistive personnel (UAP)?
1. Documenting the seizure
2. Performing neurologic checks
3. Checking the client's vital signs
4. Restraining the client for protection - ANSWER - 3
Measurement of vital signs is within the education and scope of practice of UAPs.
The nurse should perform neurologic checks and document the seizure. Clients
with seizures should not be restrained; however, the nurse may guide the client's
movements if necessary to prevent injury.
The nurse is preparing to admit a client with a seizure disorder. Which action can
be assigned to an LPN/LVN?
1. Completing the admission assessment
2. Setting up oxygen and suction equipment
3. Placing a padded tongue blade at the bedside
4. Padding the side rails before the client arrives - ANSWER - 2
The LPN/LVN scope of practice includes setting up the equipment for oxygen and
suctioning. The RN should perform the complete initial assessment. Controversy
QUESTIONS WITH CORRECT ANSWERS {VERIFIED ANSWERS}
|ALREADY GRADED A+
The nurse is assessing a client with a neurologic health problem and discovers a
change in level of consciousness from alert to lethargic. What is the nurse's best
action?
1. Perform a complete neurologic assessment.
2. Assess the cranial nerve functions.
3. Contact the Rapid Response Team.
4. Reassess the client in 30 minutes. - ANSWER - 3
A change in level of consciousness and orientation is the earliest and most reliable
indication that central neurologic function has declined. If a decline occurs,
contact the Rapid Response Team or health care provider immediately. The nurse
should also perform a focused assessment to determine if there are any other
changes
The nurse on the neurologic acute care unit is assessing the orientation of a client
with severe headaches. Which questions would the nurse use to determine
orientation? Select all that apply.
1. When did you first experience the headache symptoms?
2. Who is the Mayor of Cleveland?
3. What is your health care provider's name?
4. What year and month is this?
5. What is your parents' address?
,6. What is the name of this health care facility? - ANSWER - 1, 3, 4, 6
After determining alertness in a client, the next step is to evaluate orientation.
When the client's attention is engaged, ask him or her questions to determine
orientation. Varying the sequence of questioning on repeated assessments
prevents the client from memorizing the answers. Responses that indicate
orientation include the ability to answer questions about person, place, and time
by asking for information such as the client's ability to relate the onset of
symptoms, the name of his or her health care provider or nurse, the year and
month, his or her address, and the name of the referring physician or health care
agency. Asking about mayors' names or parents' address may be inappropriate to
assess orientation.
What is the priority nursing concern for a client experiencing a migraine
headache?
1. Pain
2. Anxiety
3. Hopelessness
4. Risk for brain injury - ANSWER - 1
The priority for interdisciplinary care for the client experiencing a migraine
headache is pain management. All of the other problems are accurate, but none
of them is as urgent as the issue of pain, which is often incapacitating.
The nurse is creating a teaching plan for a client with newly diagnosed migraine
headaches. Which key items will be included in the teaching plan? Select all that
apply.
1. Foods that contain tyramine, such as alcohol and aged cheese, should be
avoided.
2. Drugs such as nitroglycerin and nifedipine should be avoided.
3. Abortive therapy is aimed at eliminating the pain during the aura.
, 4. A potential side effect of medications is rebound headache.
5. Complementary therapies such as biofeedback and relaxation may be helpful.
6. Estrogen therapy should be continued as prescribed by the client's health care
provider. - ANSWER - 1, 2, 3, 4, 5
Medications such as estrogen supplements may actually trigger a migraine
headache attack. All of the other statements are accurate and should be included
in the teaching plan.
After a client has a seizure, which action can the nurse delegate to the unlicensed
assistive personnel (UAP)?
1. Documenting the seizure
2. Performing neurologic checks
3. Checking the client's vital signs
4. Restraining the client for protection - ANSWER - 3
Measurement of vital signs is within the education and scope of practice of UAPs.
The nurse should perform neurologic checks and document the seizure. Clients
with seizures should not be restrained; however, the nurse may guide the client's
movements if necessary to prevent injury.
The nurse is preparing to admit a client with a seizure disorder. Which action can
be assigned to an LPN/LVN?
1. Completing the admission assessment
2. Setting up oxygen and suction equipment
3. Placing a padded tongue blade at the bedside
4. Padding the side rails before the client arrives - ANSWER - 2
The LPN/LVN scope of practice includes setting up the equipment for oxygen and
suctioning. The RN should perform the complete initial assessment. Controversy
