NUR480 Exam 3 – Accurate Answers To All
Questions
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Terms in this set (231)
In planning for discharge 3. Take all of the antibiotics until gone.
planning for a client with
bacterial meningitis, the The client should be instructed to complete all
nurse will be sure to antibiotics until they are completely gone. Failure to
include which instruction? complete antibiotics may lead to re-infection and may
spread causing endocarditis and other infections in the
1. Keep all family and body, especially if the bacteria were from streptococci.
visitors from visiting your While the client may be in isolation while in the hospital,
room for protective family may not need to quarantine the client when at
isolation. home. Some family members receive prophylactic
2. Make sure you eat high antibiotics, but will be ordered according to the
protein diet with plenty of bacterial strain and health care provider (HCP)
fluids recommendations. It is important to eat a good diet, but
3. Take all of the antibiotics the most important will be taking prescribed antibiotics.
until gone. While returning to exercise is important, gradual
4. Incorporate regular increase should be performed, and the answer
exercise with an active selection for exercise was not as important as
range of motion. prescribed antibiotics.
,The nurse is assessing the 1. Supraorbital ridge pressure.
central stimulus function of
an unconscious client in the Central stimulus is applied to cranial nerves not
intensive care unit. The peripheral nerves. Supraorbital ridge pressure by
nurse should plan to use applying pressure on the orbital rim is indicated for
which technique to test the central stimulus assessment. Sternal rub is usually not
client's central response to indicated via best practices. Pressure on the nail bed
stimuli? represents testing painful stimuli for motor testing on
peripheral nerves. Calling out loudly is not an
1. Supraorbital ridge assessment technique for central stimulus function.
pressure. There are two anatomic locations for pain stimulus:
2. Sternal rub. centrally and peripherally. Central involves trapezious
3. Pressure on the nail bed. pinch or supraorbital pressure whereas peripheral
4. Calling out loudly close stimuli are applied to extremities. Responses may infer
to the client's ear. damage to the brain or specific brain areas.
,A client is admitted for 2. Perform neurological assessment and assess pupillary
observation following a response.
motor vehicle accident that
occurred on the way to the The nurse needs to perform a neuro assessment to
client's daughter's wedding. determine pupillary response, ask if a headache is
The next morning, instead present, take vital signs, and contact the health care
of asking about the provider. The client may be exhibiting subtle signs of
wedding, the client tells the increased intracranial pressure which includes
nurse "I have to leave now restlessness, agitation, headache, and pupil changes.
since the wedding is in a
few minutes." The client
then becomes agitated
when the nurse re-orients
and states the actual date
(which is the day following
the wedding). What should
the nurse do next?
1. Change the date on the
hospital room whiteboard
to yesterday's date.
2. Perform neurological
assessment and assess
pupillary response.
3. Administer Valium 40 mg
IV since the client is about
to have a seizure.
4. Call the family to see if
the wedding can be
repeated
1. Sore throat
A client is taking felbamate
2. Epistaxis
(Felbatol) for seizures and
displays symptoms of
Pancytopenia symptoms while taking felbamate include
pancytopenia based on
fever, sore throat, flu-like feeling, and may exhibit
which assessment findings?
increased bleeding with reduced platelet count
(Select all that apply)
(epitaxis). Skin rash may not indicate pancytopenia.
Gingival hyperplasia is an adverse affect of
1. Sore throat
anticonvulsants like phenytoin, but is not a symptom of
2. Epistaxis
pancytopenia. Pancytopenia affects red cells, white
3. Skin rash
cells, and platelets and represents bone marrow's
4. Gingival hyperplasia
response to on-hematologic conditions such as drugs.
, A client is being discharged 1. If stopped abruptly, status epilepticus may occur.
with a new prescription of
phenytoin sodium (dilantin). It is important to instruct not to suddenly stop taking
Which instruction by the phenytoin sodium (Dilantin) as doing so may present a
nurse is most important to risk for return of life-threatening seizure activity.
include? Sulfonamides will increase phenytoin levels. The drug
should not be taken with antacids and will lower
1. If stopped abruptly, phenytoin absorption. Clients on contraceptive
status epilepticus may hormone therapy may need to use alternative forms of
occur. non-hormonal contraceptives while on phenytoin
2. Sulfonamides like Bactrim sodium (Dilantin).
will decrease phenytoin
levels in the blood.
3. Take the medication with
antacids to reduce gastric
upset.
4. Dilantin will not affect
contraceptive
effectiveness.
The nurse is caring for a 3. Keep the client in semi-fowlers position.
client who is unconscious
who requires enteral It is most important to maintain a semi-flowlers position
feedings through a with nasogastric feedings to prevent aspiration. While
nasogastric tube. Which daily weights may be important, protecting the airway
action takes priority when and lungs from aspiration is more important. Having
managing enteral feedings? sterile water and supplies are not necessary since the
management is with clean not sterile procedure. The
1. Weigh the client daily at formula should be room temperature and should never
the same time. be heated prior to administration.
2. Make sure sterile water
and sterile gavage system
is changed every 24 hours.
3. Keep the client in semi-
fowlers position.
4. Keep the formula warm
by setting in hot water 30
minutes prior to
administration.
Questions
Save
Terms in this set (231)
In planning for discharge 3. Take all of the antibiotics until gone.
planning for a client with
bacterial meningitis, the The client should be instructed to complete all
nurse will be sure to antibiotics until they are completely gone. Failure to
include which instruction? complete antibiotics may lead to re-infection and may
spread causing endocarditis and other infections in the
1. Keep all family and body, especially if the bacteria were from streptococci.
visitors from visiting your While the client may be in isolation while in the hospital,
room for protective family may not need to quarantine the client when at
isolation. home. Some family members receive prophylactic
2. Make sure you eat high antibiotics, but will be ordered according to the
protein diet with plenty of bacterial strain and health care provider (HCP)
fluids recommendations. It is important to eat a good diet, but
3. Take all of the antibiotics the most important will be taking prescribed antibiotics.
until gone. While returning to exercise is important, gradual
4. Incorporate regular increase should be performed, and the answer
exercise with an active selection for exercise was not as important as
range of motion. prescribed antibiotics.
,The nurse is assessing the 1. Supraorbital ridge pressure.
central stimulus function of
an unconscious client in the Central stimulus is applied to cranial nerves not
intensive care unit. The peripheral nerves. Supraorbital ridge pressure by
nurse should plan to use applying pressure on the orbital rim is indicated for
which technique to test the central stimulus assessment. Sternal rub is usually not
client's central response to indicated via best practices. Pressure on the nail bed
stimuli? represents testing painful stimuli for motor testing on
peripheral nerves. Calling out loudly is not an
1. Supraorbital ridge assessment technique for central stimulus function.
pressure. There are two anatomic locations for pain stimulus:
2. Sternal rub. centrally and peripherally. Central involves trapezious
3. Pressure on the nail bed. pinch or supraorbital pressure whereas peripheral
4. Calling out loudly close stimuli are applied to extremities. Responses may infer
to the client's ear. damage to the brain or specific brain areas.
,A client is admitted for 2. Perform neurological assessment and assess pupillary
observation following a response.
motor vehicle accident that
occurred on the way to the The nurse needs to perform a neuro assessment to
client's daughter's wedding. determine pupillary response, ask if a headache is
The next morning, instead present, take vital signs, and contact the health care
of asking about the provider. The client may be exhibiting subtle signs of
wedding, the client tells the increased intracranial pressure which includes
nurse "I have to leave now restlessness, agitation, headache, and pupil changes.
since the wedding is in a
few minutes." The client
then becomes agitated
when the nurse re-orients
and states the actual date
(which is the day following
the wedding). What should
the nurse do next?
1. Change the date on the
hospital room whiteboard
to yesterday's date.
2. Perform neurological
assessment and assess
pupillary response.
3. Administer Valium 40 mg
IV since the client is about
to have a seizure.
4. Call the family to see if
the wedding can be
repeated
1. Sore throat
A client is taking felbamate
2. Epistaxis
(Felbatol) for seizures and
displays symptoms of
Pancytopenia symptoms while taking felbamate include
pancytopenia based on
fever, sore throat, flu-like feeling, and may exhibit
which assessment findings?
increased bleeding with reduced platelet count
(Select all that apply)
(epitaxis). Skin rash may not indicate pancytopenia.
Gingival hyperplasia is an adverse affect of
1. Sore throat
anticonvulsants like phenytoin, but is not a symptom of
2. Epistaxis
pancytopenia. Pancytopenia affects red cells, white
3. Skin rash
cells, and platelets and represents bone marrow's
4. Gingival hyperplasia
response to on-hematologic conditions such as drugs.
, A client is being discharged 1. If stopped abruptly, status epilepticus may occur.
with a new prescription of
phenytoin sodium (dilantin). It is important to instruct not to suddenly stop taking
Which instruction by the phenytoin sodium (Dilantin) as doing so may present a
nurse is most important to risk for return of life-threatening seizure activity.
include? Sulfonamides will increase phenytoin levels. The drug
should not be taken with antacids and will lower
1. If stopped abruptly, phenytoin absorption. Clients on contraceptive
status epilepticus may hormone therapy may need to use alternative forms of
occur. non-hormonal contraceptives while on phenytoin
2. Sulfonamides like Bactrim sodium (Dilantin).
will decrease phenytoin
levels in the blood.
3. Take the medication with
antacids to reduce gastric
upset.
4. Dilantin will not affect
contraceptive
effectiveness.
The nurse is caring for a 3. Keep the client in semi-fowlers position.
client who is unconscious
who requires enteral It is most important to maintain a semi-flowlers position
feedings through a with nasogastric feedings to prevent aspiration. While
nasogastric tube. Which daily weights may be important, protecting the airway
action takes priority when and lungs from aspiration is more important. Having
managing enteral feedings? sterile water and supplies are not necessary since the
management is with clean not sterile procedure. The
1. Weigh the client daily at formula should be room temperature and should never
the same time. be heated prior to administration.
2. Make sure sterile water
and sterile gavage system
is changed every 24 hours.
3. Keep the client in semi-
fowlers position.
4. Keep the formula warm
by setting in hot water 30
minutes prior to
administration.
