PRN 1725 EXAM 1 Latest Updated 2024 With
Complete Solutions
A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the
following manifestations of dementia should the nurse include in the teaching?
-difficulty performing ADLs
-memory loss - FORGETFULNESS
-wandering
-confusion
-repeating questions
A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client
has a positive Romberg sign. Which of the following actions should the nurse take to assess for this sign?
- Have the client stand with eyes closed and feet together - see if they sway
- tests their balance
A nurse visiting a client with Huntington's disease is asked if his offspring will also have this disease.
Which response is appropriate?
-the children have a 50% chance of inheriting it
-genetic testing can confirm it
A young adult is hospitalized with a seizure disorder. The client who is in a bed with padded rails, is
found having a tonic-clinic seizure. Which of the following actions by the nurse would require further
teaching?
- do not put anything in their mouth
- do not restrain thwm
,A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions
should the nurse perform first?
-make sure they are safe
-LOC
-stay with the person
-DO NOT move them
A nurse is caring for a client who sustained a head injury in an accident. A focused exam reveals that one
pupil is larger than the other. What should the nurse do first?
-notify the provider
Which nursing intervention is the priority when caring for a client during the acute phase of Guillain-
Barre?
-assessment is the most important part during the acute stage
-monitor the progression of paralysis
-monitor ABGs
-orthostatic hypertension and cardiac dysrhythmia
A nurse is collecting data from an infant who hit her head when she fell off a dressing table. the nurse
should identify which of the following as indicating increased intracranial pressure?
-high pitched cry
-irritability
-bulging fontanels
-setting sun (eyes looking down)
, A nurse is modifying the diet of a client who has parkinson's and a prescription for Selegiline, a MAOI.
Which of the following foods should the nurse eliminate from the clients diet.
-Aboid Tyramine
-aged cheese, cured meats, dried fruit, alcohol, pickled or fermented foods
An alert and oriented client comes to the ED after hitting his head in a motor vehicle accident. What
should the nurse do first?
stabilize neck and spine
Autonomic Dysreflexia can lead to...?
BP increase - at risk for severe hypertension and stroke
What are the risk factors for a stroke/CVA?
smoking
atherosclerosis
drug use
high BP
high cholesterol
sedentary lifestyle
Drug therapy for seizure disorder typically includes which of the following?
Anti-convulsive
ex: phenytoin
Which s/s that would indicate the client is stuporous?
Complete Solutions
A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the
following manifestations of dementia should the nurse include in the teaching?
-difficulty performing ADLs
-memory loss - FORGETFULNESS
-wandering
-confusion
-repeating questions
A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client
has a positive Romberg sign. Which of the following actions should the nurse take to assess for this sign?
- Have the client stand with eyes closed and feet together - see if they sway
- tests their balance
A nurse visiting a client with Huntington's disease is asked if his offspring will also have this disease.
Which response is appropriate?
-the children have a 50% chance of inheriting it
-genetic testing can confirm it
A young adult is hospitalized with a seizure disorder. The client who is in a bed with padded rails, is
found having a tonic-clinic seizure. Which of the following actions by the nurse would require further
teaching?
- do not put anything in their mouth
- do not restrain thwm
,A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions
should the nurse perform first?
-make sure they are safe
-LOC
-stay with the person
-DO NOT move them
A nurse is caring for a client who sustained a head injury in an accident. A focused exam reveals that one
pupil is larger than the other. What should the nurse do first?
-notify the provider
Which nursing intervention is the priority when caring for a client during the acute phase of Guillain-
Barre?
-assessment is the most important part during the acute stage
-monitor the progression of paralysis
-monitor ABGs
-orthostatic hypertension and cardiac dysrhythmia
A nurse is collecting data from an infant who hit her head when she fell off a dressing table. the nurse
should identify which of the following as indicating increased intracranial pressure?
-high pitched cry
-irritability
-bulging fontanels
-setting sun (eyes looking down)
, A nurse is modifying the diet of a client who has parkinson's and a prescription for Selegiline, a MAOI.
Which of the following foods should the nurse eliminate from the clients diet.
-Aboid Tyramine
-aged cheese, cured meats, dried fruit, alcohol, pickled or fermented foods
An alert and oriented client comes to the ED after hitting his head in a motor vehicle accident. What
should the nurse do first?
stabilize neck and spine
Autonomic Dysreflexia can lead to...?
BP increase - at risk for severe hypertension and stroke
What are the risk factors for a stroke/CVA?
smoking
atherosclerosis
drug use
high BP
high cholesterol
sedentary lifestyle
Drug therapy for seizure disorder typically includes which of the following?
Anti-convulsive
ex: phenytoin
Which s/s that would indicate the client is stuporous?
