NUR 2755 MDC 4 Exam 1

NUR 2755 MDC 4 Exam 11. A nurse is assessing a client in postoperative recovery. The client complains of the following symptoms. Which of the following is abnormal and should be reported immediately? a. Emesis that is red b. Complaint of feeling cold c. Nausea d. Complaint of pain 2. A client's neurological status deteriorates over hours, and a craniotomy is performed to evacuate a hematoma. Which nursing intervention is indicated to help decrease the threat of increased intracranial pressure? a. Elevate the head of the bed 30 degrees b. Cluster nursing interventions to provide uninterrupted periods of rest c. Teach the client to cough and deep breathe to prevent the necessity for suctioning d. Teach the client to hold his breath and bear down while repositioning in bed. 3. A client presents to the emergency room with complaints of bilateral lower extremity loss of sensation that started in the feet but has now progressed to the knees and hips. The nurse interprets these symptoms to indicate an immediate workup for which of the following diseases? a. Myasthenia gravis b. Simple, partial seizure c. guillain- barre syndrome d. Cerebrovascular accident 4. The charge nurse is obtaining the client’s signature on a surgical consent form. The client states, I didn’t really understand what my surgeon explained, but I trust him completely, “which response by the charge nurse is correct? a. I need to contact your surgeon so your questions can be answered b. I can answer any questions that you might have regarding your surgery. c. As long as you are comfortable, then you may sign the consent form. d. Maybe you should call your surgeon to be sure it is okay to sign the consent. 5. A client has a head injury and is presenting with signs and symptoms of increased intracranial pressure. Which nursing intervention would be helpful in reducing this pressure? a. Place the neck in a neutral position to promote venous drainage b. Suction hourly to stimulate the cough reflex