Med Surg 1 Final Exam
A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply)
a.) Use the Glasgow Coma Scale when assessing the client b.) Assist the client to a supine position c.) Administer an opioid medications d.) Encourgae the client to increase fluid intake e.) Instruct the client to perform deep breathing and coughing exercises - ANSWER b,c,d
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? a.) Headache b.) Infection c.) Aphasia d.) Hypertension - ANSWER b A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? a.) E2+V3+M5 = 10 b.) E3+V4+M4= 11
c.) E4+V5+M6= 15 d.) E2+V2+M4= 8 - ANSWER b
A nurse is developing a plan of care for a client who is scheduled for a cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? (Slect all that apply) a.) "I think I might be pregnant." b.) "I take warfarin." c.) "I take antihypertensive medication." d.) "I am allergic to shrimp." e.) "I ate a light breakfast this morning." - ANSWER a,b,d,e A nurse is providing a education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? a.) "Do not wash your hair the morning of the procedure." b.) "Try to stay awake most of the night prior to the procedure." c.) "The procedure will take approximately 15 minutes." d.) "You will need to lie flat for 4 hours after the procedure." - ANSWER b
A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "I am about to have a seizure." Which of the following actions should the nurse implement? a.) provide privacy
b.) Ease the client to the floor if standing c.) Move furniture away from the client d.) Loosen the client's clothing e.) Protect the client's head with padding f.) Restrain the client - ANSWER a,b,c,d,e
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? a.) Keep the client in a side-lying position b.) Document the duration of the seizure c.) Reorient the client to the environment d.) Provide client hygeine - ANSWER a
A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include? a.) Consider taking an antacid on this medication b.) Watch the receding gums when taking the medication c.) Take the medication at the same time everyday d.) Provide a urine sample to determine therapeutic levels of the medication - ANSWER c
A nurse is reviewing trigger factors that can cause seizure with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply)
a.) Avoid overwhelming fatigue b.) Remove caffeinated products from diet c.) Limit looking at flashing lights
d.) Perform aerobic exercise
A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply)
a.) Use the Glasgow Coma Scale when assessing the client b.) Assist the client to a supine position c.) Administer an opioid medications d.) Encourgae the client to increase fluid intake e.) Instruct the client to perform deep breathing and coughing exercises - ANSWER b,c,d
A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? a.) Headache b.) Infection c.) Aphasia d.) Hypertension - ANSWER b A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? a.) E2+V3+M5 = 10 b.) E3+V4+M4= 11
c.) E4+V5+M6= 15 d.) E2+V2+M4= 8 - ANSWER b
A nurse is developing a plan of care for a client who is scheduled for a cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? (Slect all that apply) a.) "I think I might be pregnant." b.) "I take warfarin." c.) "I take antihypertensive medication." d.) "I am allergic to shrimp." e.) "I ate a light breakfast this morning." - ANSWER a,b,d,e A nurse is providing a education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? a.) "Do not wash your hair the morning of the procedure." b.) "Try to stay awake most of the night prior to the procedure." c.) "The procedure will take approximately 15 minutes." d.) "You will need to lie flat for 4 hours after the procedure." - ANSWER b
A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "I am about to have a seizure." Which of the following actions should the nurse implement? a.) provide privacy
b.) Ease the client to the floor if standing c.) Move furniture away from the client d.) Loosen the client's clothing e.) Protect the client's head with padding f.) Restrain the client - ANSWER a,b,c,d,e
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? a.) Keep the client in a side-lying position b.) Document the duration of the seizure c.) Reorient the client to the environment d.) Provide client hygeine - ANSWER a
A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include? a.) Consider taking an antacid on this medication b.) Watch the receding gums when taking the medication c.) Take the medication at the same time everyday d.) Provide a urine sample to determine therapeutic levels of the medication - ANSWER c
A nurse is reviewing trigger factors that can cause seizure with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply)
a.) Avoid overwhelming fatigue b.) Remove caffeinated products from diet c.) Limit looking at flashing lights
d.) Perform aerobic exercise
