MED SURGE FINAL EXAM

1. A patient is on the floor for monitoring after being admitted following an ischemic stroke. The nurse who knows the importance of the principles of body alignment and correct positioning will prevent joint deformities by: A) Placing the patient in the prone position, laying flat, for 30 minutes a day B) Assisting the patient in acutely flexing the thigh to promote movement C) Placing a pillow in the axilla when there is limited external rotation D) Placing the patient's hand in pronation Ans: C Chapter: 62 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 4 Patient Needs: A-1 Feedback: A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the chest. The prone position with a pillow under the pelvis (not flat) promotes hyperextension of the hip joints, which is essential for normal gait. To promote venous return and prevent edema, the upper thigh should not be flexed acutely. The hand is placed in slight supination, not pronation, which is its most functional position. 2. A patient who just suffered a hemorrhagic stroke is admitted through the emergency room. The nurse's primary assessment is focused on: A) Cardiac and respiratory status B) Seizure activity C) Urinary output D) Fluid and electrolyte balance Ans: A Chapter: 62 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 4 Patient Needs: A-1 Feedback: Acute care begins with managing the ABCs. Patients may have difficulty keeping an open and clear airway secondary to a decreased level of consciousness. Neurological assessment with close monitoring for signs of increased neurological deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully with a goal of adequate hydration to promote perfusion and decrease further brain activity. 3. The nurse is caring for a patient on t-PA (tissue plasminogen activation) administration. The most common side effect of this infusion is: A) Bleeding B) Hypertension C) Migraine headache D) Flaccid paralysis Ans: A Chapter: 62 Cognitive Level: Knowledge Difficulty: Easy Integrated Process: Nursing Process Objective: 4 Patient Needs: A-1 Feedback: The most common side effect of t-PA is bleeding because thrombolytic agents, like t- PA, dissolve the blood clot that is blocking blood flow to the brain. 4. The nurse is aware that an absolute contraindication for thrombolytic therapy is seen in a patient: A) Who is anticoagulated B) Who is hypertensive C) With evidence of stroke evolution D) With symptom onset of less than 3 hours prior to admission Ans: A Chapter: 62 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 4 Patient Needs: A-1 Feedback: A patient who is anticoagulated would be at too high a risk for bleeding; thrombolytic therapy must occur within 3 hours of onset of symptoms due to revascularization of necrotic tissue which increases the risk for cerebral edema and hemorrhage.