NUR 445-Exam 3 with correct detailed answers
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A |client |is |hospitalized |in |ICU |after |a |drug |overdose. |Which |statement |would |the |nurse |interpret |as |
indicating |the |client |has |normal |mentation? |(Select |all |that |apply.)
| 1. |"Which |part |of |the |hospital |am |I |in?"
| 2. |"I |just |want |to |die."
| 3. |"I |should |have |swallowed |the |pills |with |bourbon."
| 4. |"Get |that |cat |out |of |here."
| 5. |"My |feet |are |cold." |- |CORRECT |ANSWER-Answer: |1, |2, |3, |5
A |client |reports |feeling |very |anxious |and |not |being |able |to |sleep. |The |nurse |anticipates |initially |
administering |a |drug |from |which |class |to |treat |these |disorders?
1. |Opiate |narcotics
2. |Benzodiazepines
3. |Antidepressants
4. |Neuromuscular |blockers |- |CORRECT |ANSWER-Answer: |2
Which |characteristics |would |the |nurse |attribute |to |delirium |rather |than |dementia? |(Select |all |that |
apply.)
| 1. |The |client's |mentation |was |clear |until |he |was |hospitalized |last |week.
| 2. |The |client |does |not |recognize |his |children.
| 3. |The |client |has |periods |of |clarity |that |alternate |with |confusion.
| 4. |The |client's |family |reports |his |confusion |has |become |steadily |more |pronounced |over |the |last |year
|5. |The |client |continually |tries |to |get |out |of |bed |stating, |"I've |got |to |get |off |this |- |CORRECT |ANSWER-
Answer: |1, |3
A |nurse |is |concerned |that |a |hospitalized |client |may |be |developing |delirium. |Which |interventions |are |
indicated? |(Select |all |that |apply.)
| 1. |Ask |the |family |to |bring |the |client's |eyeglasses |from |home.
,| 2. |Turn |room |lights |down |at |night |to |encourage |sleep.
| 3. |Maintain |bed |rest |until |mentation |improves.
| 4. |Remove |the |television |from |the |room.
| 5. |Review |the |client's |medication |list. |- |CORRECT |ANSWER-Answer: |1, |2, |5
The |nurse |discovers |a |client |having |a |seizure. |What |should |be |the |nurse's |initial |action?
| 1. |Roll |the |client |onto |his |or |her |side.
| 2. |Intubate |the |client |immediately.
| 3. |Administer |pentobarbital.
| 4. |Establish |an |IV |line. |- |CORRECT |ANSWER-Answer: |1
A |client |experiencing |continued |seizure |activity |is |to |be |given |propofol. |The |nurse |should |prepare |for |
which |other |intervention?
| 1. |Administration |of |insulin
| 2. |Mechanical |ventilation
| 3. |Placement |of |an |oral |airway
| 4. |Administration |of |a |neuromuscular |blocking |agent |- |CORRECT |ANSWER-Answer: |2
A |client |experienced |an |episode |of |vision |loss |and |right-side |weakness |that |lasted |4 |hours |before |
totally |resolving. |What |information |should |the |nurse |provide |to |this |client?
| 1. |"Your |symptoms |indicate |that |you |have |had |a |subarachnoid |hemorrhage."
| 2. |"While |these |symptoms |have |resolved, |your |risk |for |a |stroke |is |higher."
| 3. |"These |symptoms |often |occur |in |older |clients |and |are |nothing |to |worry |about."
|4. |"Your |stroke |involved |the |occipital |lobe |and |your |vision |will |dim |over |the |next |few |weeks." |- |
CORRECT |ANSWER-Answer: |2
A |client |suffered |a |stroke |yesterday |and |has |recovered |partial |function. |The |client's |spouse |says, |"I |
don't |understand |what |is |happening. |When |my |mother |had |a |stroke, |she |was |left |in |a |coma |for |years
|before |she |died." |What |is |the |nurse's |best |response?
| 1. |"All |strokes |are |different."
, | 2. |"Each |client |responds |differently."
| 3. |"There |are |different |levels |of |damage |done |by |strokes."
| 4. |"Your |mother |must |have |had |some |additional |medical |problems." |- |CORRECT |ANSWER-Answer: |3
An |82-year-old |African |American |man |has |a |history |of |hypertension, |type |1 |diabetes, |and |had |a |
stroke |two |years |ago. |He |is |a |smoker |and |admits |to |leading |a |sedentary |life |style. |The |nurse |analyzes |
this |information |to |determine |that |the |client |has |________ |non-modifiable |risk |factors |for |stroke. |- |
CORRECT |ANSWER-4: |age, |gender, |ethnicity, |and |history |of |previous |stroke.
A |nurse's |neighbor |calls |and |reports |that |her |64-year-old |husband |is |complaining |about |loss |of |vision |
in |one |eye |after |mowing |the |lawn |on |a |hot |Sunday |afternoon. |He |is |awake |and |alert |and |says |the |
vision |loss |came |on |slowly |over |about |an |hour. |What |advice |should |the |nurse |give?
1. |"Have |him |lie |down |and |cool |off |and |see |if |his |vision |is |better."
| 2. |"Call |his |physician's |answering |service |and |ask |them |to |relay |the |information |to |the |doctor."
| 3. |"Give |him |a |cold |drink |and |I |will |be |over |as |soon |as |I |finish |lunch |to |check |on |him."
| 4. |"Take |him |to |urgent |care |or |the |emergency |room." |- |CORRECT |ANSWER-Answer: |4
A |patient |who |had |a |stroke |has |decreased |level |of |consciousness, |headache, |and |is |vomiting. |Using |
this |information, |which |nursing |diagnosis |should |the |nurse |assign?
1. |Impaired |Skin |Integrity
2. |Acute |Pain
3. |Decreased |Intracranial |Adaptive |Capacity
4. |Activity |Intolerance |- |CORRECT |ANSWER-Answer: |3
A |client |is |receiving |an |infusion |of |tPA |for |treatment |of |acute |ischemic |stroke. |The |nurse |would |
immediately |discontinue |this |infusion |if |the |client |manifested |which |assessment |finding? |(Select |all |
that |apply.)
| 1. |Nausea
| 2. |Severe |headache
| 3. |Elevation |of |blood |pressure |to |180/100
| 4. |Atrial |fibrillation
| 5. |Decrease |in |pedal |pulse |amplitude |- |CORRECT |ANSWER-Answer: |1, |2, |3, |5
| | | | | |
A |client |is |hospitalized |in |ICU |after |a |drug |overdose. |Which |statement |would |the |nurse |interpret |as |
indicating |the |client |has |normal |mentation? |(Select |all |that |apply.)
| 1. |"Which |part |of |the |hospital |am |I |in?"
| 2. |"I |just |want |to |die."
| 3. |"I |should |have |swallowed |the |pills |with |bourbon."
| 4. |"Get |that |cat |out |of |here."
| 5. |"My |feet |are |cold." |- |CORRECT |ANSWER-Answer: |1, |2, |3, |5
A |client |reports |feeling |very |anxious |and |not |being |able |to |sleep. |The |nurse |anticipates |initially |
administering |a |drug |from |which |class |to |treat |these |disorders?
1. |Opiate |narcotics
2. |Benzodiazepines
3. |Antidepressants
4. |Neuromuscular |blockers |- |CORRECT |ANSWER-Answer: |2
Which |characteristics |would |the |nurse |attribute |to |delirium |rather |than |dementia? |(Select |all |that |
apply.)
| 1. |The |client's |mentation |was |clear |until |he |was |hospitalized |last |week.
| 2. |The |client |does |not |recognize |his |children.
| 3. |The |client |has |periods |of |clarity |that |alternate |with |confusion.
| 4. |The |client's |family |reports |his |confusion |has |become |steadily |more |pronounced |over |the |last |year
|5. |The |client |continually |tries |to |get |out |of |bed |stating, |"I've |got |to |get |off |this |- |CORRECT |ANSWER-
Answer: |1, |3
A |nurse |is |concerned |that |a |hospitalized |client |may |be |developing |delirium. |Which |interventions |are |
indicated? |(Select |all |that |apply.)
| 1. |Ask |the |family |to |bring |the |client's |eyeglasses |from |home.
,| 2. |Turn |room |lights |down |at |night |to |encourage |sleep.
| 3. |Maintain |bed |rest |until |mentation |improves.
| 4. |Remove |the |television |from |the |room.
| 5. |Review |the |client's |medication |list. |- |CORRECT |ANSWER-Answer: |1, |2, |5
The |nurse |discovers |a |client |having |a |seizure. |What |should |be |the |nurse's |initial |action?
| 1. |Roll |the |client |onto |his |or |her |side.
| 2. |Intubate |the |client |immediately.
| 3. |Administer |pentobarbital.
| 4. |Establish |an |IV |line. |- |CORRECT |ANSWER-Answer: |1
A |client |experiencing |continued |seizure |activity |is |to |be |given |propofol. |The |nurse |should |prepare |for |
which |other |intervention?
| 1. |Administration |of |insulin
| 2. |Mechanical |ventilation
| 3. |Placement |of |an |oral |airway
| 4. |Administration |of |a |neuromuscular |blocking |agent |- |CORRECT |ANSWER-Answer: |2
A |client |experienced |an |episode |of |vision |loss |and |right-side |weakness |that |lasted |4 |hours |before |
totally |resolving. |What |information |should |the |nurse |provide |to |this |client?
| 1. |"Your |symptoms |indicate |that |you |have |had |a |subarachnoid |hemorrhage."
| 2. |"While |these |symptoms |have |resolved, |your |risk |for |a |stroke |is |higher."
| 3. |"These |symptoms |often |occur |in |older |clients |and |are |nothing |to |worry |about."
|4. |"Your |stroke |involved |the |occipital |lobe |and |your |vision |will |dim |over |the |next |few |weeks." |- |
CORRECT |ANSWER-Answer: |2
A |client |suffered |a |stroke |yesterday |and |has |recovered |partial |function. |The |client's |spouse |says, |"I |
don't |understand |what |is |happening. |When |my |mother |had |a |stroke, |she |was |left |in |a |coma |for |years
|before |she |died." |What |is |the |nurse's |best |response?
| 1. |"All |strokes |are |different."
, | 2. |"Each |client |responds |differently."
| 3. |"There |are |different |levels |of |damage |done |by |strokes."
| 4. |"Your |mother |must |have |had |some |additional |medical |problems." |- |CORRECT |ANSWER-Answer: |3
An |82-year-old |African |American |man |has |a |history |of |hypertension, |type |1 |diabetes, |and |had |a |
stroke |two |years |ago. |He |is |a |smoker |and |admits |to |leading |a |sedentary |life |style. |The |nurse |analyzes |
this |information |to |determine |that |the |client |has |________ |non-modifiable |risk |factors |for |stroke. |- |
CORRECT |ANSWER-4: |age, |gender, |ethnicity, |and |history |of |previous |stroke.
A |nurse's |neighbor |calls |and |reports |that |her |64-year-old |husband |is |complaining |about |loss |of |vision |
in |one |eye |after |mowing |the |lawn |on |a |hot |Sunday |afternoon. |He |is |awake |and |alert |and |says |the |
vision |loss |came |on |slowly |over |about |an |hour. |What |advice |should |the |nurse |give?
1. |"Have |him |lie |down |and |cool |off |and |see |if |his |vision |is |better."
| 2. |"Call |his |physician's |answering |service |and |ask |them |to |relay |the |information |to |the |doctor."
| 3. |"Give |him |a |cold |drink |and |I |will |be |over |as |soon |as |I |finish |lunch |to |check |on |him."
| 4. |"Take |him |to |urgent |care |or |the |emergency |room." |- |CORRECT |ANSWER-Answer: |4
A |patient |who |had |a |stroke |has |decreased |level |of |consciousness, |headache, |and |is |vomiting. |Using |
this |information, |which |nursing |diagnosis |should |the |nurse |assign?
1. |Impaired |Skin |Integrity
2. |Acute |Pain
3. |Decreased |Intracranial |Adaptive |Capacity
4. |Activity |Intolerance |- |CORRECT |ANSWER-Answer: |3
A |client |is |receiving |an |infusion |of |tPA |for |treatment |of |acute |ischemic |stroke. |The |nurse |would |
immediately |discontinue |this |infusion |if |the |client |manifested |which |assessment |finding? |(Select |all |
that |apply.)
| 1. |Nausea
| 2. |Severe |headache
| 3. |Elevation |of |blood |pressure |to |180/100
| 4. |Atrial |fibrillation
| 5. |Decrease |in |pedal |pulse |amplitude |- |CORRECT |ANSWER-Answer: |1, |2, |3, |5
