Nurs 384 Final Study Guide Questions With
Complete Solutions
1. A patient with left-sided weakness that started 60 minutes earlier is admitted
to the Emergency Department and diagnostic tests are ordered. Which test
should be done first?
a. Complete blood count (CBC)
b. Chest radiography (Chest x-ray)
c. 12-Lead electrocardiogram (ECG)
d. Non-contrast computed tomography (CT) scan - Answer-Answer D Non-
contrast computed tomography (CT) scan
Rationale: To screen for stroke symptoms quickly a non-contrast CT scan is
required before administering tissue plasminogen activator (tPA) within 4.5
hours. Giving tPA sooner reduces damage to brain tissue. Diagnostic tests can
reveal the possible causes of the stroke but they are not as urgent as the CT scan.
2. A 72-year-old patient with a history of a transient ischemic attack (TIA) has an
order for aspirin 160 mg daily. When the nurse administers medications the
patient says I don't need the aspirin today. I don't have a fever. Which action
should the nurse take?
a. Document that the ASA was refused by the patient.
,b. Tell the patient that the aspirin is used to prevent a fever.
c. Explain that aspirin is ordered to decrease stroke.
d. Call the healthcare provider to clarify the medication order - Answer-Answer C
Explain that aspirin is ordered to decrease stroke.
Rationale: Patients who have experienced TIAs are prescribed aspirin to prevent
further occurrences. If a patient refuses to take the medication simply
documenting the refusal is insufficient. It's not required to confirm the order with
the healthcare provider. It's important to understand that aspirin is not given to
relieve headaches or pains.
11. You're developing a nursing care plan for a patient in the diuresis stage of AKI.
What nursing diagnosis would you include in the care plan?
a. Excess fluid volume
b. Risk for electrolyte imbalance
c. Urinary retention
d. Acute pain - Answer-Answer: B. Risk for electrolyte imbalance
Rationale: During the diuresis stage of AKI the patient will be losing an excessive
amount of urine and is at risk for fluid volume deficient and electrolyte imbalance.
12. A patient with AKI has a urinary output of 350 mL/day. In addition morning
labs showed an increased BUN and creatinine level along with potassium level of
6 mEq/L. What type of diet ordered by the physician is most appropriate for this
patient?
a. Low-sodium high-protein and low-potassium
b. High-protein low-potassium and low-sodium
c. Low-protein low-potassium and low-sodium
d. High-protein and high-potassium - Answer-Answer C. The patient with AKI
especially in the oliguric stage of AKI should eat a low-protein low-potassium and
,low-sodium diet. This is because the kidneys are unable to filter out waste
products excessive water and maintain electrolyte balance.
13. A patient arrives at the emergency department with slurred speech right facial
droop and right arm weakness. Which of these actions by the healthcare provider
is the priority?
a. Call the speech pathologist to the emergency department.
b. Administer a thrombolytic medication.
c. Prepare the patient for a CT scan of the head.
d. Transfer the patient to the neurological care unit. - Answer-The answer is C.
This is intervention is priority because "time is brain."
14. The healthcare provider is assessing a patient admitted with a diagnosis of
hemorrhagic stroke affecting the right cranial hemisphere. Which assessment
finding is consistent with this diagnosis?
a. Kernig sign
b. Right sided spasticity
c. Bilateral Babinski's sign
d. Left sided flaccidity. - Answer-The answer is D. A patient who has sustained
damage to the right cranial hemisphere will experience loss of motor function on
the left side of the body.
15. During discharge teaching to a patient at risk for developing osteoporosis you
discuss the types of exercise the patient should perform. Which type of exercise is
not the best to perform to prevent osteoporosis?
a. Tennis
, b. Weight-lifting
c. Walking
d. Hiking - Answer-The answer is C. Low-impact exercises are not as beneficial in
building bone mass as compared to weight-bearing exercises such as tennis lifting
weights and hiking etc.
16. The oliguric phase of acute kidney injury (AKI) involves less than how many mL
of urine per day?
a. < 300 mL/day
b. < 400 mL/day
c. < 500 mL/day
d. < 600 mL/day - Answer-Answer: B <400 ml/day
Rationale: Clinical manifestations of the oliguric phase of AKI include < 400
mL/day. This occurs 1-7 days after injury and can last up to 10-14 days. An
individual's urinalysis may show casts RBCs and WBCs.
17. Osteoporosis is more common in women than men. True or false?
a. True
b. False - Answer-Answer: True
Rationale: Osteoporosis is more common in women than men because women
typically have lower calcium intake than men less bone mass because of a smaller
frame and bone resorption begins earlier and accelerates after menopause.
18. Stroke is the fifth most common cause of death in the United States and is
also the leading cause of serious long-term disability. True or false?
Complete Solutions
1. A patient with left-sided weakness that started 60 minutes earlier is admitted
to the Emergency Department and diagnostic tests are ordered. Which test
should be done first?
a. Complete blood count (CBC)
b. Chest radiography (Chest x-ray)
c. 12-Lead electrocardiogram (ECG)
d. Non-contrast computed tomography (CT) scan - Answer-Answer D Non-
contrast computed tomography (CT) scan
Rationale: To screen for stroke symptoms quickly a non-contrast CT scan is
required before administering tissue plasminogen activator (tPA) within 4.5
hours. Giving tPA sooner reduces damage to brain tissue. Diagnostic tests can
reveal the possible causes of the stroke but they are not as urgent as the CT scan.
2. A 72-year-old patient with a history of a transient ischemic attack (TIA) has an
order for aspirin 160 mg daily. When the nurse administers medications the
patient says I don't need the aspirin today. I don't have a fever. Which action
should the nurse take?
a. Document that the ASA was refused by the patient.
,b. Tell the patient that the aspirin is used to prevent a fever.
c. Explain that aspirin is ordered to decrease stroke.
d. Call the healthcare provider to clarify the medication order - Answer-Answer C
Explain that aspirin is ordered to decrease stroke.
Rationale: Patients who have experienced TIAs are prescribed aspirin to prevent
further occurrences. If a patient refuses to take the medication simply
documenting the refusal is insufficient. It's not required to confirm the order with
the healthcare provider. It's important to understand that aspirin is not given to
relieve headaches or pains.
11. You're developing a nursing care plan for a patient in the diuresis stage of AKI.
What nursing diagnosis would you include in the care plan?
a. Excess fluid volume
b. Risk for electrolyte imbalance
c. Urinary retention
d. Acute pain - Answer-Answer: B. Risk for electrolyte imbalance
Rationale: During the diuresis stage of AKI the patient will be losing an excessive
amount of urine and is at risk for fluid volume deficient and electrolyte imbalance.
12. A patient with AKI has a urinary output of 350 mL/day. In addition morning
labs showed an increased BUN and creatinine level along with potassium level of
6 mEq/L. What type of diet ordered by the physician is most appropriate for this
patient?
a. Low-sodium high-protein and low-potassium
b. High-protein low-potassium and low-sodium
c. Low-protein low-potassium and low-sodium
d. High-protein and high-potassium - Answer-Answer C. The patient with AKI
especially in the oliguric stage of AKI should eat a low-protein low-potassium and
,low-sodium diet. This is because the kidneys are unable to filter out waste
products excessive water and maintain electrolyte balance.
13. A patient arrives at the emergency department with slurred speech right facial
droop and right arm weakness. Which of these actions by the healthcare provider
is the priority?
a. Call the speech pathologist to the emergency department.
b. Administer a thrombolytic medication.
c. Prepare the patient for a CT scan of the head.
d. Transfer the patient to the neurological care unit. - Answer-The answer is C.
This is intervention is priority because "time is brain."
14. The healthcare provider is assessing a patient admitted with a diagnosis of
hemorrhagic stroke affecting the right cranial hemisphere. Which assessment
finding is consistent with this diagnosis?
a. Kernig sign
b. Right sided spasticity
c. Bilateral Babinski's sign
d. Left sided flaccidity. - Answer-The answer is D. A patient who has sustained
damage to the right cranial hemisphere will experience loss of motor function on
the left side of the body.
15. During discharge teaching to a patient at risk for developing osteoporosis you
discuss the types of exercise the patient should perform. Which type of exercise is
not the best to perform to prevent osteoporosis?
a. Tennis
, b. Weight-lifting
c. Walking
d. Hiking - Answer-The answer is C. Low-impact exercises are not as beneficial in
building bone mass as compared to weight-bearing exercises such as tennis lifting
weights and hiking etc.
16. The oliguric phase of acute kidney injury (AKI) involves less than how many mL
of urine per day?
a. < 300 mL/day
b. < 400 mL/day
c. < 500 mL/day
d. < 600 mL/day - Answer-Answer: B <400 ml/day
Rationale: Clinical manifestations of the oliguric phase of AKI include < 400
mL/day. This occurs 1-7 days after injury and can last up to 10-14 days. An
individual's urinalysis may show casts RBCs and WBCs.
17. Osteoporosis is more common in women than men. True or false?
a. True
b. False - Answer-Answer: True
Rationale: Osteoporosis is more common in women than men because women
typically have lower calcium intake than men less bone mass because of a smaller
frame and bone resorption begins earlier and accelerates after menopause.
18. Stroke is the fifth most common cause of death in the United States and is
also the leading cause of serious long-term disability. True or false?
