NCLEX TYPE QUESTIONS
The nurse witnesses a patient’s seizure involving generalized contraction of the body followed by jerkiness of arms and leg. The nurse reports this as what kind of seizure?
A.myoclonic
B.absence
C.tonic-clonic
D.psychomotor
C.tonic-clonic
Don't leave me lying here! Turn me on my ____
Left side
After intubation you can confirm ETT placement by doing this
hat is auscultating the lungs and CXR, end tidal co2
watching chest movement
A client experiences a right-sided pneumothorax. The nurse recognizes that there is danger of a mediastinal shift, which could cause which life-threatening condition?
A. Rupture of the pericardium
B. Infection of the subpleural lining
C. Decreased filling of the right side of the heart
D. Increased volume of the unaffected lung
C. Decreased filling of the right side of the heart
Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side. This not only decreases the capacity of the unaffected lung but also impedes the filling of the right side of the heart and leads to a decreased cardiac output. Rupture of the pericardium might occur with severe chest trauma, not with a mediastinal shift. Infection is not caused by a mediastinal shift. The volume of the unaffected lung may decrease because of pressure from the shift.
A seizure lasting more than 5 mins is _____________
status epilepticus
nurse is completing discharge teaching to a client who has seizures and receives a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching?
A.” it is safe to use microwaves that are 1200 watts or less”
B. “ you should avoid the use of CT scan with contrast”
C. “ you should place a magnet over the implantable device when you feel an aura coming”
D. “ it is recommended that you use ultrasound diathermy for pain management”
C. “ you should place a magnet over the implantable device when you feel an aura coming”
Document ________ and duration of seizure and findings prior to, during, and following the seizure.
onset
What is the generic name for the common anti-anxiety drug Ativan?
What is Lorazepam
Which assessment finding on a client who has just had a thoracentesis for a right pleural effusion would require the most rapid action by the nurse?
A. Oxygen saturation of 93%
B. Blood pressure of 160/94 mm Hg
C. Decreased right side breath sounds
D. Ecchymosis at the site of the thoracentesis
.
C. Decreased right side breath sounds
After thoracentesis the breath sounds should be audible on the affected side and decreased breath sounds may indicate pneumothorax. The nurse would immediately notify the health care provider and expect actions such as a chest x-ray and possible insertion of a chest tube. The oxygen saturation of 93% is slightly below normal, but would not be surprising in a client who has a history of lung disease. Hypotension after thoracentesis may indicate bleeding or that too much pleural fluid has been removed at once, but mild hypertension may occur due to anxiety or pain. Ecchymosis at the thoracentesis site would be monitored, but would be expected after thoracentesis
Bradycardia
Hypertension
Widening pulse pressure
What is Cushing's Triad?
Which question by the patient having cerebral angiography indicates that teaching has been effective?
A. “This is a fairly simple x-ray test, right?”
B. “Is it unusual if I get hot and flushed when you inject the dye?”
C. “My kidneys have to be in good shape to get this dye, right?”
D. “Is this test to see if an infection is causing my problem?”
C. “My kidneys have to be in good shape to get this dye, right?”
A person who is at high risk for actual or potential life-threatening health problems and who requires intense and vigilant nursing care.
What is the definition of a CRITICALLY ill patient?
Sleep deprivation, anxiety, sensory overload, and immobilization are these types of factors contributing to delerium in ICU patients.
What is ICU psychosis?
The most severe form of acute lung injury
ARDS
Which nursing action is a priority for a client with a spinal cord injury who has developed sudden autonomic dysreflexia?
A. Place in a sitting position.
B. Give nifedipine as prescribed.
C. Examine for symptoms of pressure injuries.
D. Monitor blood pressure (BP) every 10 to 15 minutes.
A. Place in a sitting position.
Clients with spinal cord injuries are at an increased risk for developing autonomic dysreflexia. Autonomic dysreflexia is a condition in which the client has very high BP. The first step in this situation is to assist the client into a sitting position because it naturally reduces BP. The nurse can give nifedipine as prescribed, but only after assisting the client into a sitting position. The nurse can examine the symptoms of pressure injuries after stabilizing the client. The nurse would monitor client’s BP every 10 to 15 minutes after stabilizing the client.
A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures?(select all that apply)
a)Avoid overwhelming fatigue.
B) Remove caffeinated products from diet
C)Limit looking at flashing lights.
D)Perform Aerobic exercise.
A,B,C
What is the term that describes: Give another person permission to perform a task on your behalf.
Delegate
A belief system in which group members declare to each other and the public the shared competency standards and ethical values of their discipline
What is professionalism?
Which findings will cause the nurse to suspect cardiac tamponade in a client who has had cardiac surgery? Select all that apply.
A. Hypertension
B. Pulsus paradoxus
C. Muffled heart sounds
D. Jugular vein distention
E. Increased urine output
B. Pulsus paradoxus
C. Muffled heart sounds
D. Jugular vein distention
Pulsus paradoxus is present in cardiac tamponade. Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid, thready pulse and muffled heart sounds. The increased venous pressure associated with cardiac tamponade causes jugular vein distention. Tamponade causes hypotension, not hypertension, and a narrowed pulse pressure. As the cardiac output decreases, there is a decrease in kidney perfusion and a decrease in urine output.
When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? Select all that apply.
A. Bradycardia
B. Hypotension
C. Spastic paralysis
D. Urinary retention
E. Increased pulse pressure
A. Bradycardia
B. Hypotension
D. Urinary retention
Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in vasodilation and hypotension. Urinary retention may occur in spinal shock because of autonomic nervous system dysfunction. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform?
A) keep the client in a side -lying position.
B)Document duration of the seizure.
C) Reorient the client to the environment.
D Provide client hygiene.
Keep the client in a side lying position
What are the 5 delegation rights?
Right Task
Right Circumstance
Right Person
Right Direction
Right Supervision
Regulations are made under this Act about the class of registration, title protection, controlled acts, practice requirements, quality assurance, and professional misconduct.
What is the Nursing Practice Act?
Your 63 year old patient with chronic bronchitis reports fatigue, SOB, shallow respirations difficulty thinking, and anorexia. ABG,s pH 7.30 PaCO2 68 mm,Hg HCO3=29mEq/L The patients extremities are cold and pale. WBC 12.5 serum potassium 5.8 The CXR report shows consolidation in the lower lobes. Please interpret the ABG's PaO2=65mm Hg
What is Respiratory Acidosis (COPD Related)
Suddent onset of severe, throbbing headache, Severe, rapidly occuring hypertension, bradycardia, flushing above the level of the lesion, nausea, and piloerection are all signs of this emergent condition
What is autonomic dysreflexia