Matching questions
1-125 of 125
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Question 3 of 20
The nurse is caring for a client diagnosed with a vertebrobasilar artery stroke. What
assessment finding would the nurse expect for this client?
Ataxia
Amnesia
Unilateral neglect
Aphasia
Give this one a try later!
, A- Ataxia
Aphasia, amnesia, and unilateral neglect are common assessment findings
associated with cerebral strokes. Clients who have vertebrobasilar artery
strokes have dysfunctions of the cerebellum, such as ataxia, and possibly
the brainstem. Clients with this type of stroke typically have weakness in all
four extremities rather than one-sided weakness.
(Question 11)
After being intubated and placed on mechanical ventilation, Ms. A is transported to
the radiology department. The CT scans indicate that she has a large epidural
hematoma. In addition, chest and left leg radiographs show that she has a left femur
fracture and evidence of aspiration pneumonia.
When the nurse reassesses Ms. A, she is flaccid and has no response to verbal or
painful stimulation. Her pupils are dilated and nonreactive to light. Vital sign values
are:
Blood pressure 190/40 mm Hg
Heart rate 40 beats/min (sinus bradycardia)
O2 saturation 92% (0.92)
Respiratory rate 14 breaths/min (ventilator controlled)
Temperature 96.4° F (35.6° C) (tympanic)
Which complication is the nurse most concerned about at present?
1.
Brainstem herniation
2.
Respiratory acidosis
3.
Hemorrhage
4.
Hypothermia
Give this one a try later!
, 1
Rationale:
The client's fixed and dilated pupils, widened pulse pressure, and
bradycardia are caused by increasing pressure on the brainstem and
indicate that she is at risk for brainstem herniation, which would result in
brain death. Immediate surgical intervention is needed to prevent this
complication. She is at risk for the other complications, but they are not as
life threatening.
Focus: Prioritization
A client who has Alzheimer disease is hospitalized with new-onset angina. Her spouse
tells the nurse that he does not sleep well because he needs to be sure the client
does not wander during the night. He insists on checking each of the medications the
nurse gives the client to be sure they are "the same pills she takes at home." Based on
this information, which nursing problem is most appropriate for this client?
1.
Acute client confusion
2.
Care provider role stress
3.
Increased risk for falls
4.
Noncompliance with therapeutic plan
Give this one a try later!
, 2. Care provider role stress
Rationale:
The husband's statement about lack of sleep and concern about whether
his wife is receiving the correct medications are behaviors that support the
problem of care provider role stress. The husband's statements about how
he monitors the client and his concern with medication administration do
not indicate difficulty complying with the therapeutic plan. The client may
be confused, but the nurse would need to gather more data, and this is not
the main focus of the husband's concerns. Falls are not an immediate
concern at this time.
Focus: Prioritization
QSEN: Patient-Centered Care
Concept: Caregiving
Which of the following statements by a patient who is undergoing antineoplastic
therapy would be of concern to the nurse? (Select all that apply.)
"I have attended a meeting of a cancer support group."
"My husband and I are planning a short trip next week."
"I am eating six small meals plus two protein shakes a day."
"I am taking my 15-month-old granddaughter to the pediatrician next week for her
baby shots."
"I am going to go shopping at the mall next week."
Give this one a try later!
Answer: 4, 5 Rationale: Patients and family members should avoid receiving
live virus vaccinations or exposure to chickenpox. The patient could have
an exacerbation or a more pronounced episode of the disease. The patient
should not care for the granddaughter if vaccination with live viruses is
planned. The patient should also avoid crowds, especially in enclosed
spaces when possible, to minimize exposure risk. The nurse should discuss
measures to minimize the risk of infections if the patient desires to go
shopping. Options 1, 2, and 3 are incorrect. Attending a support group,
maintaining normal activities when possible, and eating small, frequent
1-125 of 125
Click a definition to match it with a term
Question 3 of 20
The nurse is caring for a client diagnosed with a vertebrobasilar artery stroke. What
assessment finding would the nurse expect for this client?
Ataxia
Amnesia
Unilateral neglect
Aphasia
Give this one a try later!
, A- Ataxia
Aphasia, amnesia, and unilateral neglect are common assessment findings
associated with cerebral strokes. Clients who have vertebrobasilar artery
strokes have dysfunctions of the cerebellum, such as ataxia, and possibly
the brainstem. Clients with this type of stroke typically have weakness in all
four extremities rather than one-sided weakness.
(Question 11)
After being intubated and placed on mechanical ventilation, Ms. A is transported to
the radiology department. The CT scans indicate that she has a large epidural
hematoma. In addition, chest and left leg radiographs show that she has a left femur
fracture and evidence of aspiration pneumonia.
When the nurse reassesses Ms. A, she is flaccid and has no response to verbal or
painful stimulation. Her pupils are dilated and nonreactive to light. Vital sign values
are:
Blood pressure 190/40 mm Hg
Heart rate 40 beats/min (sinus bradycardia)
O2 saturation 92% (0.92)
Respiratory rate 14 breaths/min (ventilator controlled)
Temperature 96.4° F (35.6° C) (tympanic)
Which complication is the nurse most concerned about at present?
1.
Brainstem herniation
2.
Respiratory acidosis
3.
Hemorrhage
4.
Hypothermia
Give this one a try later!
, 1
Rationale:
The client's fixed and dilated pupils, widened pulse pressure, and
bradycardia are caused by increasing pressure on the brainstem and
indicate that she is at risk for brainstem herniation, which would result in
brain death. Immediate surgical intervention is needed to prevent this
complication. She is at risk for the other complications, but they are not as
life threatening.
Focus: Prioritization
A client who has Alzheimer disease is hospitalized with new-onset angina. Her spouse
tells the nurse that he does not sleep well because he needs to be sure the client
does not wander during the night. He insists on checking each of the medications the
nurse gives the client to be sure they are "the same pills she takes at home." Based on
this information, which nursing problem is most appropriate for this client?
1.
Acute client confusion
2.
Care provider role stress
3.
Increased risk for falls
4.
Noncompliance with therapeutic plan
Give this one a try later!
, 2. Care provider role stress
Rationale:
The husband's statement about lack of sleep and concern about whether
his wife is receiving the correct medications are behaviors that support the
problem of care provider role stress. The husband's statements about how
he monitors the client and his concern with medication administration do
not indicate difficulty complying with the therapeutic plan. The client may
be confused, but the nurse would need to gather more data, and this is not
the main focus of the husband's concerns. Falls are not an immediate
concern at this time.
Focus: Prioritization
QSEN: Patient-Centered Care
Concept: Caregiving
Which of the following statements by a patient who is undergoing antineoplastic
therapy would be of concern to the nurse? (Select all that apply.)
"I have attended a meeting of a cancer support group."
"My husband and I are planning a short trip next week."
"I am eating six small meals plus two protein shakes a day."
"I am taking my 15-month-old granddaughter to the pediatrician next week for her
baby shots."
"I am going to go shopping at the mall next week."
Give this one a try later!
Answer: 4, 5 Rationale: Patients and family members should avoid receiving
live virus vaccinations or exposure to chickenpox. The patient could have
an exacerbation or a more pronounced episode of the disease. The patient
should not care for the granddaughter if vaccination with live viruses is
planned. The patient should also avoid crowds, especially in enclosed
spaces when possible, to minimize exposure risk. The nurse should discuss
measures to minimize the risk of infections if the patient desires to go
shopping. Options 1, 2, and 3 are incorrect. Attending a support group,
maintaining normal activities when possible, and eating small, frequent
