CVA
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?
Prepare the patient for a computerized tomography (CT) scan of the head
The healthcare provider understands that teaching has been effective when the patient verbalizes the following regarding influenza vaccinations:
“The vaccine is an inactivated virus, but may cause some mild cold-like symptoms.”
The client has a chronic peptic ulcer and wants to know the difference between an acute and chronic peptic ulcer. How does the nurse educate the client?
A chronic ulcer has scarring, takes longer to heal, but an acute ulcer only goes through submucosa, causes superficial erosion and minimal inflammation.
A patient diagnosed with an acute ischemic stroke is to receive alteplase (tPA) 0.9 mg/kg IV. The patient weighs 187 pounds. How many mg will be administered to the patient?
76.5 mg
What should be the main focus of nursing management for a client hospitalized for cholecystitis?
Assessment for complications
A patient who is recovering from a cerebral vascular accident (CVA) is experiencing bladder distention, urinary frequency, oliguria, and leakage of urine. The healthcare provider suspects these findings are related to which of these urinary problems?
Overflow incontinence
In order to prevent ventilator associated/ acquired pneumonia (VAP) in an intubated patient, the healthcare provider should:
Provide oral care and suctioning to the patient
The nurse is caring for a client with peptic ulcer disease due to H. pylori. Which drug combinations should be given along with a macrolide antibiotic?
PPI, amoxicillin if triple therapy
Use metronidazole if allergic to amoxicillin
A patient who has hemianopia is at risk for injury. What can you educate the patient to perform regularly to prevent injury?
Scanning the room from side to side frequently
A client is taking an antacid for treatment of a peptic ulcer. What statement made by the patient informs the nurse the client understands how to take the medication?
I should take the medication when I have symptoms or about 1-3 hours after eating.
A patient tells the healthcare provider, “Yesterday I felt numbness in my right hand, my vision became blurry, and I felt like I was losing my balance, but after I laid down for about an hour it went away.” What is the healthcare provider’s best response?
"This may be a warning sign of a stroke.”
A pediatric patient has been diagnosed with right lower lobe pneumonia. Upon auscultation of this lung field, the healthcare provider would expect to hear which breath sound?
Crackles
A nurse is providing discharge teaching to a client who just had a cholecystectomy and has a T-Tube. Which of the following statements by the client indicate that further education is required?
"I will keep my T-tube clamped at all times."
A nurse is caring for a client who is recovering from a stroke. The nurse arranges for a swallowing screening to be performed. What is the purpose of this test?
To assess the amount of dysphagia present
An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. What assessment is anticipated for dehydration?
Hypothermia
hypertension
Distended neck veins
Tachycardia
Tachycardia
The healthcare provider is assessing a patient who experienced a thrombotic stroke. Which of these is the priority assessment?
Pupillary response
A patient was admitted to the intensive care unit 48 hours ago for treatment of a gunshot wound. The patient has recently developed a productive cough and a fever of 104.3 'F. The patient is breathing on their own and doesn't require mechanical ventilation. On assessment, you note coarse crackles in the right lower lobe. A chest x-ray shows infiltrates with consolidation in the right lower lobe. Based on this specific patient scenario, this is known as what type of pneumonia?
Hospital-acquired pneumonia
The client with peptic ulcer disease is prescribed sucralfate. What outcome should the nurse anticipate?
ulcer healing
A 70-year-old client has balance problems as a result of a stroke. A nurse has been seeing this client in the home for continued monitoring of medication regimens and personal care. Based on the nurse’s knowledge of the client’s medical condition, the nurse knows that balance problems can cause what?
Falls when walking or transferring from one area to another
A client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, what is the rationale for holding a cane on the uninvolved side?
distribute weight away from the involved side
A patient is admitted to the medical unit after being diagnosed with a cerebral vascular accident (CVA). The healthcare provider will initially place the patient in a __ position.
Lateral
You're educating a patient with pneumonia on how to deep breathe by using an incentive spirometer. What instructions do you provide?
A. Encourage the patient to use it twice a day.
B. The patient exhales into the device rapidly and then coughs.
C. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales.
D. The patient rapidly inhales 10 times from the device and then exhales for 6 seconds.
The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales.
Two days after a patient has had gastric surgery, the nurse suspects that the patient’s nasogastric tube is not in the correct position. What should the nurse do?
Contact the NCP since the client is 2 days post-op gastric surgery.
What are some intermediate and rehabilitative care needs for a client with stroke?
Maintain a consistent daily routine, Position for body alignment and comfort, Maintain upright position after eating, Speech therapy to facilitate swallowing, occupational therapy for ADLs
If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse anticipates that the client has problems with:
body temperature control