NURS 480 EXAM 3 QUESTIONS AND ANSWERS
(VERIFIED AND WELL DETAILED ANSWERS
GRADED A+)
In planning for discharge planning for a client with bacterial meningitis, the nurse will
| | | | | | | | | | | | |
be sure to include which instruction?
| | | | | |
1. Keep all family and visitors from visiting your room for protective isolation.
| | | | | | | | | | |
2. Make sure you eat high protein diet with plenty of fluids
| | | | | | | | | |
3. Take all of the antibiotics until gone. | | | | | |
4. Incorporate regular exercise with an active range of motion. -- CORRECT | | | | | | | | | |
ANSWER -3. Take all of the antibiotics until gone.
| | | | | | | | |
The client should be instructed to complete all antibiotics until they are completely
| | | | | | | | | | | |
gone. Failure to complete antibiotics may lead to re-infection and may spread
| | | | | | | | | | | |
causing endocarditis and other infections in the body, especially if the bacteria were
| | | | | | | | | | | | |
from streptococci. While the client may be in isolation while in the hospital, family
| | | | | | | | | | | | | |
may not need to quarantine the client when at home. Some family members receive
| | | | | | | | | | | | | |
prophylactic antibiotics, but will be ordered according to the bacterial strain and
| | | | | | | | | | | |
health care provider (HCP) recommendations. It is important to eat a good diet, but
| | | | | | | | | | | | | |
the most important will be taking prescribed antibiotics. While returning to exercise
| | | | | | | | | | | |
is important, gradual increase should be performed, and the answer selection for
| | | | | | | | | | | |
exercise was not as important as prescribed antibiotics.
| | | | | | | |
The nurse is assessing the central stimulus function of an unconscious client in the
| | | | | | | | | | | | |
intensive care unit. The nurse should plan to use which technique to test the client's
| | | | | | | | | | | | | | |
central response to stimuli?
| | | |
,1. Supraorbital ridge pressure. | |
2. Sternal rub. |
3. Pressure on the nail bed. | | | |
4. Calling out loudly close to the client's ear. -- CORRECT ANSWER -1.
| | | | | | | | | | |
Supraorbital ridge pressure.
| | |
Central stimulus is applied to cranial nerves not peripheral nerves. Supraorbital ridge
| | | | | | | | | | |
pressure by applying pressure on the orbital rim is indicated for central stimulus
| | | | | | | | | | | | |
assessment. Sternal rub is usually not indicated via best practices.
| | | | | | | | | |
Pressure on the nail bed represents testing painful stimuli for motor testing on
| | | | | | | | | | | |
peripheral nerves. Calling out loudly is not an assessment technique for central
| | | | | | | | | | | |
stimulus function. There are two anatomic locations for pain stimulus: centrally and
| | | | | | | | | | | |
peripherally. Central involves trapezious pinch or supraorbital pressure whereas
| | | | | | | | |
peripheral stimuli are applied to extremities. Responses may infer damage to the brain
| | | | | | | | | | | | |
or specific brain areas.
| | | |
A client is admitted for observation following a motor vehicle accident that occurred
| | | | | | | | | | | |
on the way to the client's daughter's wedding. The next morning, instead of asking
| | | | | | | | | | | | | |
about the wedding, the client tells the nurse "I have to leave now 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 -- CORRECTANSWER -2.
| | | | | | | | | | | | | |
Perform neurological assessment and assess pupillary response.
| | | | | | |
,The nurse needs to perform a neuro assessment to determine pupillary response, ask
| | | | | | | | | | | |
if a headache is present, take vital signs, and contact the health care provider. The
| | | | | | | | | | | | | | |
client may be exhibiting subtle signs of increased intracranial pressure which
| | | | | | | | | | |
includes restlessness, agitation, headache, and pupil changes.
| | | | | | |
A client is taking felbamate (Felbatol) for seizures and displays symptoms of
| | | | | | | | | | |
pancytopenia based on which assessment findings? (Select all that apply)
| | | | | | | | | |
1. Sore throat |
2. Epistaxis
3. Skin rash |
4. Gingival hyperplasia -- CORRECT ANSWER -1. Sore throat | | | | | | |
2. Epistaxis
|
Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-like
| | | | | | | | |
feeling, and may exhibit increased bleeding with reduced platelet count (epitaxis).
| | | | | | | | | | |
Skin rash may not indicate pancytopenia. Gingival hyperplasia is an adverse affect of
| | | | | | | | | | | | |
anticonvulsants like phenytoin, but is not a symptom of pancytopenia.
| | | | | | | | | |
Pancytopenia affects red cells, white cells, and platelets and represents bone | | | | | | | | | |
marrow's response to on-hematologic conditions such as drugs.
| | | | | | | |
A client is being discharged with a new prescription of phenytoin sodium (dilantin).
| | | | | | | | | | | |
Which instruction by the nurse is most important to include?
| | | | | | | | | |
1. If stopped abruptly, status epilepticus may occur.
| | | | | |
2. Sulfonamides like Bactrim will decrease phenytoin levels in the blood. | | | | | | | | |
, 3. Take the medication with antacids to reduce gastric upset.
| | | | | | | |
4. Dilantin will not affect contraceptive effectiveness. -- CORRECT ANSWER -1. If
| | | | | | | | | |
stopped abruptly, status epilepticus may occur.
| | | | | |
It is important to instruct not to suddenly stop taking phenytoin sodium (Dilantin) as
| | | | | | | | | | | | |
doing so may present a risk for return of life-threatening seizure activity.
| | | | | | | | | | | |
Sulfonamides will increase phenytoin levels. The drug should not be taken with | | | | | | | | | | |
antacids and will lower phenytoin absorption. Clients on contraceptive hormone
| | | | | | | | | |
therapy may need to use alternative forms of non-hormonal contraceptives while
| | | | | | | | | | |
on phenytoin sodium (Dilantin).
| | | |
The nurse is caring for a client who is unconscious who requires enteral feedings
| | | | | | | | | | | | |
through a nasogastric tube. Which action takes priority when managing enteral
| | | | | | | | | | |
feedings?
|
1. Weigh the client daily at the same time. | | | | | | |
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.
| | | | | | | | | | | | |
-- CORRECT ANSWER -3. Keep the client in semi-fowlers position.
| | | | | | | | | |
It is most important to maintain a semi-flowlers position with nasogastric feedings to
| | | | | | | | | | | |
prevent aspiration. While daily weights may be important, protecting the airway and
| | | | | | | | | | | |
lungs from aspiration is more important. Having sterile water and supplies are not
| | | | | | | | | | | | |
necessary since the management is with clean not sterile procedure. The formula
| | | | | | | | | | | |
should be room temperature and should never be heated prior to administration.
| | | | | | | | | | | |
(VERIFIED AND WELL DETAILED ANSWERS
GRADED A+)
In planning for discharge planning for a client with bacterial meningitis, the nurse will
| | | | | | | | | | | | |
be sure to include which instruction?
| | | | | |
1. Keep all family and visitors from visiting your room for protective isolation.
| | | | | | | | | | |
2. Make sure you eat high protein diet with plenty of fluids
| | | | | | | | | |
3. Take all of the antibiotics until gone. | | | | | |
4. Incorporate regular exercise with an active range of motion. -- CORRECT | | | | | | | | | |
ANSWER -3. Take all of the antibiotics until gone.
| | | | | | | | |
The client should be instructed to complete all antibiotics until they are completely
| | | | | | | | | | | |
gone. Failure to complete antibiotics may lead to re-infection and may spread
| | | | | | | | | | | |
causing endocarditis and other infections in the body, especially if the bacteria were
| | | | | | | | | | | | |
from streptococci. While the client may be in isolation while in the hospital, family
| | | | | | | | | | | | | |
may not need to quarantine the client when at home. Some family members receive
| | | | | | | | | | | | | |
prophylactic antibiotics, but will be ordered according to the bacterial strain and
| | | | | | | | | | | |
health care provider (HCP) recommendations. It is important to eat a good diet, but
| | | | | | | | | | | | | |
the most important will be taking prescribed antibiotics. While returning to exercise
| | | | | | | | | | | |
is important, gradual increase should be performed, and the answer selection for
| | | | | | | | | | | |
exercise was not as important as prescribed antibiotics.
| | | | | | | |
The nurse is assessing the central stimulus function of an unconscious client in the
| | | | | | | | | | | | |
intensive care unit. The nurse should plan to use which technique to test the client's
| | | | | | | | | | | | | | |
central response to stimuli?
| | | |
,1. Supraorbital ridge pressure. | |
2. Sternal rub. |
3. Pressure on the nail bed. | | | |
4. Calling out loudly close to the client's ear. -- CORRECT ANSWER -1.
| | | | | | | | | | |
Supraorbital ridge pressure.
| | |
Central stimulus is applied to cranial nerves not peripheral nerves. Supraorbital ridge
| | | | | | | | | | |
pressure by applying pressure on the orbital rim is indicated for central stimulus
| | | | | | | | | | | | |
assessment. Sternal rub is usually not indicated via best practices.
| | | | | | | | | |
Pressure on the nail bed represents testing painful stimuli for motor testing on
| | | | | | | | | | | |
peripheral nerves. Calling out loudly is not an assessment technique for central
| | | | | | | | | | | |
stimulus function. There are two anatomic locations for pain stimulus: centrally and
| | | | | | | | | | | |
peripherally. Central involves trapezious pinch or supraorbital pressure whereas
| | | | | | | | |
peripheral stimuli are applied to extremities. Responses may infer damage to the brain
| | | | | | | | | | | | |
or specific brain areas.
| | | |
A client is admitted for observation following a motor vehicle accident that occurred
| | | | | | | | | | | |
on the way to the client's daughter's wedding. The next morning, instead of asking
| | | | | | | | | | | | | |
about the wedding, the client tells the nurse "I have to leave now 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 -- CORRECTANSWER -2.
| | | | | | | | | | | | | |
Perform neurological assessment and assess pupillary response.
| | | | | | |
,The nurse needs to perform a neuro assessment to determine pupillary response, ask
| | | | | | | | | | | |
if a headache is present, take vital signs, and contact the health care provider. The
| | | | | | | | | | | | | | |
client may be exhibiting subtle signs of increased intracranial pressure which
| | | | | | | | | | |
includes restlessness, agitation, headache, and pupil changes.
| | | | | | |
A client is taking felbamate (Felbatol) for seizures and displays symptoms of
| | | | | | | | | | |
pancytopenia based on which assessment findings? (Select all that apply)
| | | | | | | | | |
1. Sore throat |
2. Epistaxis
3. Skin rash |
4. Gingival hyperplasia -- CORRECT ANSWER -1. Sore throat | | | | | | |
2. Epistaxis
|
Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-like
| | | | | | | | |
feeling, and may exhibit increased bleeding with reduced platelet count (epitaxis).
| | | | | | | | | | |
Skin rash may not indicate pancytopenia. Gingival hyperplasia is an adverse affect of
| | | | | | | | | | | | |
anticonvulsants like phenytoin, but is not a symptom of pancytopenia.
| | | | | | | | | |
Pancytopenia affects red cells, white cells, and platelets and represents bone | | | | | | | | | |
marrow's response to on-hematologic conditions such as drugs.
| | | | | | | |
A client is being discharged with a new prescription of phenytoin sodium (dilantin).
| | | | | | | | | | | |
Which instruction by the nurse is most important to include?
| | | | | | | | | |
1. If stopped abruptly, status epilepticus may occur.
| | | | | |
2. Sulfonamides like Bactrim will decrease phenytoin levels in the blood. | | | | | | | | |
, 3. Take the medication with antacids to reduce gastric upset.
| | | | | | | |
4. Dilantin will not affect contraceptive effectiveness. -- CORRECT ANSWER -1. If
| | | | | | | | | |
stopped abruptly, status epilepticus may occur.
| | | | | |
It is important to instruct not to suddenly stop taking phenytoin sodium (Dilantin) as
| | | | | | | | | | | | |
doing so may present a risk for return of life-threatening seizure activity.
| | | | | | | | | | | |
Sulfonamides will increase phenytoin levels. The drug should not be taken with | | | | | | | | | | |
antacids and will lower phenytoin absorption. Clients on contraceptive hormone
| | | | | | | | | |
therapy may need to use alternative forms of non-hormonal contraceptives while
| | | | | | | | | | |
on phenytoin sodium (Dilantin).
| | | |
The nurse is caring for a client who is unconscious who requires enteral feedings
| | | | | | | | | | | | |
through a nasogastric tube. Which action takes priority when managing enteral
| | | | | | | | | | |
feedings?
|
1. Weigh the client daily at the same time. | | | | | | |
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.
| | | | | | | | | | | | |
-- CORRECT ANSWER -3. Keep the client in semi-fowlers position.
| | | | | | | | | |
It is most important to maintain a semi-flowlers position with nasogastric feedings to
| | | | | | | | | | | |
prevent aspiration. While daily weights may be important, protecting the airway and
| | | | | | | | | | | |
lungs from aspiration is more important. Having sterile water and supplies are not
| | | | | | | | | | | | |
necessary since the management is with clean not sterile procedure. The formula
| | | | | | | | | | | |
should be room temperature and should never be heated prior to administration.
| | | | | | | | | | | |
