Adult-Neurological
The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the clients peripheral response to pain?
1) Sternal Rub
2) Nailbed Pressure
3) Pressure on the orbital rim
4) Squeezing of the sternocleidomastoid muscle
Answer:2)- nailed pressure
Nailed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal run, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
The nurse is conducting a health screening for osteoporosis. Which client is at greatest risk of developing this problem?
1) A 25-year old woman who runs
2) A 36-year old man who has asthma
3) A 70-year old man who consumes excess alcohol
4) A sedentary 65 year old woman who smokes cigarettes
Answer: 4
Risk factors for osteoporosis inclide female gender, being postmenopausal, advanced age, a low calcium diet, excessive alcohol intake, being sedentary, smoking cigarettes. Long term use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk
The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client risk factors, the nurse should question the client about an allergy to which food item?
1) Eggs
2) Milk
3) Yougurt
4) Bananas
Answer: 4
Individuals who are allergic to kiwis, bananas and pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross reaction between the food and the latex allergen.
The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?
1) "You need to stop that behaviour"
2) "You will beed to be placed in seclusion"
3) "You seem restless, tell me what is happening"
4) "You will beed to be restrained if you do not change your behaviour"
Answer: 3
The most appropriate statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behaviour and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behaviour that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.
A client is brought to the ER with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply
1) Restrict fluids
2) Assess for airway patency
3) Administer oxygen as prescribed
4) Place a cooling blanket on the client
5) Elevate extremities if no fractures are present
6) Prepare to give oral pain medications as prescribed
Answer: 2,3,5
The primary goal for a burn injury is to maintain a patent airway, administer IV fluid to prevent hypovelemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway latency and maintain patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed in NPO status because of the altered GI function that occurs as a result of a burn
1) Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
2) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
3) Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
4) Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
Answer: 2
A change in vital signs may be a late sign of increased intracranial pressure, Trends include increasing temperature and blood pressure, and decreasing pulse and respirations. Respiratory irregularities may occur.
The nurse witness a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take?
1) Try to reduce the fracture manually
2) Assist the victim ti get up and walk to the sidewalk
3) Leave the victim for a few moments to call an ambulance
4) Stay with the victim and encourage hum or her to remain still
Answer: 4
With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan?
1) Protecting the client from infection
2) Providing emotional support to decrease fear
3) Encouraging discussion about lifestyle changes
4) Identifying factors that decrease the immune function
Answer: 1
The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection.
A depressed client on an inpatient unit says to the nurse " My family would be better off without me". Which is the nurses best response?
1) "Have you talked to your family about this?"
2) "Everyone feels this way when they are depressed"
3) "You will feel better once your medications begin to work"
4) "You sound vert upset. Are you thinking of hurting yourself?"
Answer: 4
Clients who are depressed may be at risk for suicide. It is critical or the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self harm exists. Options 1, 2, and 3 do not deal directly with the clients feelings
The nurse is caring for a client experiencing acute lower GI bleeding. In developing the plan of care, which priority problem should the nurse assign to this client?
1) Deficient fluid volume related to acute blood loss
2) Risk for aspiration related to acute bleeding in the GI tract
3) Risk for infection related to acute disease process and medications
4) Imbalanced nutrition, less than body requirements related to lack of nutrients and increased metabolism
Answer: 1
The priority problem for the client with acute GI bleeding among these options is deficient fluid volume related to acute blood loss. This state can result in decreased cardiac output and hypovolemic shock. Although nutrition is a problem, fluid deficit is more of a priority. The client is at risk for aspiration and infection, but these are not actual problems at this point in time
The nurse instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the clients safety? Select all that apply.
1) Padding the side rails of the bed
2) Placing an airway at the bedside
3) Placing the bed in a high position
4) Putting a padded tongue blade ate the head of the bed
5) Placing oxygen and suction equipment at the bedside
6) Flushing the IV catheter to ensure the site is patent
Answer: 1,2,5,6
A client with diabetes mellitus has had a right below the knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery?
1) Hemorrhage
2) Edema of the residual limb
3) Slight redness od the incision
4) Separation of the wound edges
Answer: 4
Clients with diabetes are more prone to wound infection, wound separation, and delayed wound healing because of the disease. Oistoperative hemorrhage and edema of the residual limb are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as the incision is dried and intact
A client calls the nurse in the emergency department and states that he was just stung by a bee while gardening. The client is afraid of severe reaction because the clients neighbour experienced such a reaction just 1 week ago. Which action should the nurse take?
1) Advise the client to soak the site in hydrogen peroxide
2) Ask the client if he ever sustained a bee sting in the past
3) Tell the client to call an ambulance for transport to the ER
4) Tell the client to not worry about the sting unless difficult with breathing occurs
Answer: 2
In some types of allergies, a reaction occurs only on a second and subsequent contacts with allergens. The appropriate action, therefore, would be to ask the client if he ever experienced a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry"
The police arrive at the ER with a client who has lacerated both wrists. Which is the initial nursing action?
1) Administer an anti anxiety agent.
2) Assess and treat the wound sites
3) Secure and record a detailed history
4) Encourage and assist the client to ventilate feelings
Answer: 2
The initial nursing action is to assess and treat the sea inflicted injuries. Injuries from the lacerated wrists can lead to a life threatening situation. Other interventions, such as options 1,3, and 4 may follow after the client has been treated medically
The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client?
1) Administration of digoxin.
2) Administration of whole blood
3) Administration of IV fluids
4) Administration of packed red blood cells
Answer 1:
The client in this question is likely experiencing cariogenic shock secondary to heat failure exacerbation. It is important to note that If the shock state is cariogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic medications such as digoxin, dopamine, or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. Whole blood, IV fluids, and packed red blood cells are volume expanding fluids and may further complicate the clients clinical status, therefore, they should be avoided.
The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports complications of the disorder, the nurse should bring which most essential items to the clients room?
1) Nebulizer and pulse oximeter
2) Blood pressure cuff and flashlight
3) Nasal cannula and incentive spirometer
4) Electrocardiographic monitoring electrodes and intubation tray
Answer: 4
The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of ECG monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.
The nurse is assessing the casted extremity of a client. Which sign is indicative of infection?
1) Dependant edema
2) Diminished distal pulse
3) Presence of "hot spot" on the cast
4) Coolness and pallor of the extremity
Answer: 3
Sign of infection under a casted area include odour or purulent drainage from the cast or the presence of "hot spots", which are areas of the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor under the skin, diminished distal pulse, and edema
A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply
1) Administer oxygen
2) Quickly assess the clients respiratory status
3) Document the event, interventions, and clients response
4) Leave the client briefly to contact a primary health care provider
5) Keep the client supine regardless of blood pressure readings
6) Start an IV infusion of D5W and administer a 500-mL bolus
Answer: 1,2,3
An anaphylactic reaction requires immediate action, starting with quickly assessing the clients respiratory status. Although the PHCP, ,and rapid response team must be notified immediately, the nurse must stay with the client. Oxygen is administered an an IV of normal saline is started and infused as per PHCP prescription. Documentation of the event, actions taken and client outcomes needs to be performed. The head of the bed should be elevated if the clients blood pressure is normal.
A client is admitted to the mental health unit after attempted suicide by hanging. The nurse can best ensure client safety by which action?
1) Requesting that a peer remained with the client at all times
2) Removing the clients clothing and placing the client in a hospital gown
3) Assigning to the client a staff member who will remain with the client at all times
4) Admitting the client to a seclusion room where all potentially dangerous articles are removed.
Answer: 3
Hanging is a serious suicide attempt. The plan of care must reflect action to ensures the clients safety. Constant observation status (one-to-one) with a staff member is the best choice. Placing a client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. Seclusion should not be the initial intervention, and the least restrictive measure should be used.
A client in shock develops a central venous pressure (CVP) of 2mm Hg and mean arterial pressure (MAP) of 60mm Hg. Which prescribed intervention should the nurse implement first?
1) Increase the rate of 02 flow
2) Obtain arterial blood gas results
3) Insert an indwelling urinary catheter
4) Increase the rate of IV fluids
Answer: 4
The MAP and CVP are both low for this client, indicating a shock state. Shock us the result of inadequate tissue perfusion. Fluid volume should be immediately restored first to provide adequate perfusion for the client in a shock state. Although increasing the rate of 02 flow may be a necessary intervention, perfusion is the first priority. Obtaining arterial blood gas results and insetting an indwelling catheter may be necessary interventions to monitor the clients response to prescribed therapy, but these are not the priority
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicated that spinal shock persists?
1) Hyperreflexia
2) Positive reflexes
3) Flaccid paralysis
4) Reflex emptying of the bladder
Answer: 3
Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli) a state of hyper-reflexia rather than flaccidity, and reflex emptying of the bladder
A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor?
1) Bed rest
2) Ibuprofen
3) Bending or lifting
4) Application of heat
Answer: 3
Low back pain that radiates down 1 leg (sciatica) is consistent with herniated lumbar disk. The nurse assess the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg raising test). Bed rest, heat (or sometimes ice) and NSAIDS usually relieve back pain.
A client presents at the primary health care providers office with complaints of ring-like rash on his upper leg. Which question should the nurse ask first?
1) "Do you have any cats in your home?"
2) "Have you been camping in the last month?"
3) "Have you or close contacts had any flu-like-symptoms within the last few weeks?"
4) "Have you been in physical contact with anyone who has the same type of rash?"
Answer: 2
The nurse should ask questions to assist in identifying a cause of Lyme disease, which is a multi system infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ring-like rash occurring 3-4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, upper arms or legs. Option 1 is referring to toxoplasmosis, which is caused by the inhalation of cysts from contaminated cat faces. Lyme disease cannot be transmitted from one person to another.
The ER nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions?
1) Information regarding shelters
2) Instructions regarding calling the police
3) Instructions regarding self defence classes
4) Explaining the importance of leaving the violent situation
Answer: 1
Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including specific plan for removing the self from the abuser and information regarding escape, hotlines and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but specific plan is necessary.
A client had a 1L bag of 5% Dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The IV bag has 400mls remaining. The nurse should take which action first?
1) Slow the IV infusion
2) Sit the client up in bed
3) Remove the IV catheter
4) Call the Primary Health Care Provider
Answer: 1
The clients symptoms are compatible with circulatory overload. This may be verified by noting that the 600ml has infused over the course of 45 mins. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the clients breathing, if necessary. The nurse also notices the PHCP. The IV catheter is not removed; it may be needed for the administration of medications to resolve the complication.