Stroke
A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply!)
A. Impulse control difficulty
B. Left hemiplegia
C. Loss of depth preception
D. Aphasia
E. Lack of situational awareness
A, B, C, and E.
A client who has experienced a right-hemispheric stroke will:
* exhibit impulse control difficulty, such as the urgency to use the restroom.
* exhibit left-sided hemiplegia.
* experience a loss in depth preception.
* demonstrate a lack of situational awareness of surroundings.
The other chose of D. is typical for Left-hemispheric stroke, where the language centers of the brain are located.
A nurse is caring for a client who is post-procedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply!)
A. Use the Glasgow Coma Scale when assessing the client.
B. Assist the client to a supine position.
C. Administer an opioid medication
D. Encourage the client to increase fluid intake.
E. Instruct the client to perform deep breathing and coughing exercises.
B., C., and D
A is not correct because the Glasgow Coma Scale is used to assess a client's level of consciousness and is not necessary following a lumbar puncture.
E. is not correct because coughing can increase Intracranial pressure.
B. IS correct because the nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture.
C. is correct because the nurse should administer an opioid medication for a client's report of headache pain.
D. is correct because the nruse should encourage an increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture.
A nurse is assessing a client with manifestations of Parkinson's disease. Which of the following are expected findings? (Select all that apply!)
A. Decreased vision
B. Pill-rolling tremor of the fingers
C. Shuffling gait
D. Drooling
E. Bilateral ankle edema
F. Lack of facial expression
C., D., and F.
A is NOT correct because decreased vision is not an expected finding in a client who has PD.
E. is NOT correct because Bilateral ankle edema is not an expected finding in a client who has PD, but can be an adverse effect of certain medications used for treatment.
B. IS correct The client who has PD can manifest pill-rolling tremors of the fingers due to overstimulation of the basal ganglia by acetylcholine, making controlled movements difficult.
C. IS correct because the client who has PD can manifes shuffling gait because of overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.
D. The client who has PD can manifest drolling because of overstimulation of the basal ganglia by acetylcholine, making controlled movement of swallowing secretions difficult.
F. IS correct because the client who has PD can manifest a lack of facial expressions due to the overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.
A patient who is hospitalized with pneumonia is disoriented and confused 2 days after admission. Which information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia?
a. The patient was oriented and alert when admitted.
b. The patient's speech is fragmented and incoherent.
c. The patient is disoriented to place and time but oriented to person.
d. The patient has a history of increasing confusion over several years.
a. The patient was oriented and alert when admitted.
The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.
A nurse in a clinic is caring for a client who has frequent migraine headaches. Teh client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods?
A. Baked salmon
B. Salted Cashews
C. Frozen Strawberries
D. Fresh asparagus
B. is correct because nuts contain tyramine, which can trigger migraine headaches.
Baked salmon is NOT smoked, but smoked fish would contain tyramine.
Fruits are not a source of tyramine.
Vegetables are not a source of tyramine.
A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following are possible or expected findings? (Select all that apply!)
A. Impulse control difficulty
B. Poor judgement
C. Agnosia
D. Acrodynia
E. Aphasia
C. and E.
Agnosia - the inability to recognize familiar objects.
Aphasia - loss of ability to understand (receptive aphasia) or express speech (expressive aphasia).
Incorrect: Acrodynia - Pain in the extremities (the hands and feet)- absence of feeling, but not pain. Poor judgement and impulse control difficulty is associated with RIGHT-hemispheric stoke.
A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? (Select all that apply!)
A. "I think I might be pregnant."
B. "I take warfarin."
C. "I take antihypertensive medication."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning."
A.,B., D., E.
C is NOT correct because there is no contraindication related to contrast dyes for a client who is taking antihypertensive medication.
A. IS correct because the nurse should report the client's statement of possible pregnancy to the provider because the contrast dye can place the fetus at risk.
B. IS correct because the nruse should report that the client is taking warfarin to the provider due to the potential for bleeding following aniography.
D. is correct because the nurse should report a client's report of allergy to shrimp, which is a shellfish, to the provider due to a potential allergic reaction to the contrast dye.
E. is correct because the nruse should report a client's intake of food to the provider since the client should remain NPO for 4 to 6 hours prior to the procedure.
A nurse is providing teaching to the partner of an older adult client who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates teaching is effective?
A. "This medication should increase my husband's appetite."
B. "This medication should help my husband sleep better."
C. "This medication should help my husband's daily function."
D. "This medication should increase my husband's energy level."
C. Is correct. Donepezil helps slow the progression of Altz (AD) and can help improve behavior and daily functions.
Donepezil does NOT affect appetite, sleep or sleep patterns, nor energy levels.
When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include?
a. Provide complete personal hygiene care for the patient.
b. Remind the patient frequently about being in the hospital.
c. Reposition the patient frequently to avoid skin breakdown.
d. Place suction at the bedside to decrease the risk for aspiration.
b. Remind the patient frequently about being in the hospital.
The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.
A 72-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find
a. excessive nighttime sleepiness.
b. difficulty eating and swallowing.
c. variable ability to perform simple tasks.
d. loss of both recent and long-term memory.
d. loss of both recent and long-term memory.
Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?
A. Teach the client to scan to the right to see objects on the right side of her body.
B. Place the bedside table on the right side of the bed.
C. Orient the client to the food on her plate using the clock method.
D. Place the wheelchair on the client's left side.
Correct answer is: B. The client is unable to visualize to the left mid-line of her body. Placing the bedside table on the right side of the client's bed will permit visualization of items on the table.
Incorrect Answer rationale:
A. A client who has left homonymous hemianopia has lost the left visual field of both eyes. The client should be taught to turn his head to the LEFT to visualize the entire field of vision.
C. Using the clock method of food placement will be ineffective because only half of the plate can be seen.
D. The wheelchair should be placed to the client's RIGHT (the unaffected side).
A nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescription for bromocriptine. Which of the following instructions should the nruse include in the teaching?
A. Rise slowly when standing.
B. Expect urine to because dark-colored.
C. Avoid foods containing tyramine.
D. Report any skin discoloration.
A. is correct because orthostatic hypotension is a common adverse effect of bromocriptine, a dopamine receptor agonist. Therefore, rising slowly when standing up will decrease the risk of dizziness and lightheadedness.
B. is NOT correct because the urine turns dark when taking entacapone, a COMT inhibitor. Dark urine is not an expected finding when taking bromocriptine.
C. is NOT correct because the client should avoid tyramine in the diet when taking selegiline, a monoamine type B inhibitor. However, bromocriptine does NTO interact with foods that contain tyramine.
D. is NOT correct because Skin discoloration is an adverse effect of amantadine, an anti-viral medication. However, it is NOT an adverse effect of bromocriptine.
A nurse working in a long-term acute care facility is planning care for a client in stage V of Altzheimer's disease. Which of the following interventions should be included in the plan of care?
A. Use a gait belt for ambulation.
B. Thicken all liquids.
C. Provide protective undergarments.
D. Assist with ADL's.
D. is correct because a cleint in stage V of AD requires assistance with ADL's as increasing congitive deficits emerge.
A. Ambulation is affected as the client advances into stage VII of AD.
B. Impaired swallowing is a finding as the client advances into stage VII of AD.
C. The client in stages VI and VII of Alzheimer's disease experiences episodes of urinary and fecal incontinence.
When administering a mental status examination to a patient with delirium, the nurse should
a. medicate the patient first to reduce any anxiety.
b. give the examination when the patient is well-rested.
c. reorient the patient as needed during the examination.
d. choose a place without distracting environmental stimuli.
d. choose a place without distracting environmental stimuli.
Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.
When teaching the children of a patient who is being evaluated for Alzheimer's disease (AD) about the disorder, the nurse explains that
a. the most important risk factor for AD is a family history of the disorder.
b. new drugs have been shown to reverse AD dramatically in some patients.
c. a diagnosis of AD can be made only when other causes of dementia have been ruled out.
d. the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.
c. a diagnosis of AD can be made only when other causes of dementia have been ruled out.
The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm an AD diagnosis.
A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care (Select all that apply!)
A. Have the suction equpment available for use.
B. Feed the client thickened liquids.
C. Place food on the unaffected side of the client's mouth.
D. Assign an assistive personnel to feed the client slowly.
E. Teach the client to swallow with her neck flexed.
A. B. C. and E.
A. Suction equipment should be available in case of choking and aspiration.
B. The client should be given liquids that are thicker than water to prevent aspiration.
C. Placing food on the unaffected side of the client's mouth will allow her to have better control of the food and reduce the risk of aspiration.
E. The client should be taught to flex her neck, tucking the chin down and under to close the epiglottis during swallowing.
Incorrect: D. Due to the risk of aspiration, assistive personnel should NOT be assigned to feed the client because the client's swallowing ability should be assessed, and suctioning can be needed if choking occurs.
A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (Select all that apply!)
A. Areas of parethesia
B. Involuntary eye movement
C. Alopecia
D. Increased salivation
E. Ataxia
A., B., D., and E.
C is NOT correct because hair loss is NOT a finding in a client who has MS.
A. Areas of loss of skin sensation are a finding in a client who has MS.
B. Nystagmus is a finding in a client who has MS.
D. is correct because Dysphagia, swallowing difficulty, IS a finding in a client who has MS.
E. Ataxia (impaired coordination) occurs in the client who has MS as muscle weakness develops and there is a loss of coordination.
A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe?
A. Keep the call light near the client.
B. Place the client in a room close to the nurses' station.
C. Encourage the client to ask for assistance.
D. Remind the client to walk with someone for support.
B. is correct beacause, using the safety and risk reduction priority setting framework, placing the client in close proximity to the nruses' station for close observation is the first action the nurse should take.
Call light - client might not remember to use it.
Client might not remember to ask for assistance.
cCient might not remember to call for assistance.
To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to
a. secure the patient in bed using a soft chest restraint.
b. ask the health care provider about ordering an antipsychotic drug.
c. instruct family members to remain with the patient and prevent injury.
d. assign a nursing assistant to stay with the patient and offer frequent reorientation.
d. assign a nursing assistant to stay with the patient and offer frequent reorientation.
The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation.
A nurse in a provider's office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? (Select all that apply.)
A. Pain is bilateral across the posterior occipital area.
B. Client experiences altered sleep-wake cycles.
C. Headache occurs at approximately the same time of the day.
D. Client describes the headache pain as dull and throbbing.
E. Nasal congestion and drainage occur.
B. C. and E.
A. is NOT correct because cluster headaches typically cause pain on one side of the head and radiate to the forehead, temple. or cheek.
D. is NOT correct because cluster headaches are described as unilateral, intense, and non-throbbing.
B. IS correct because cluster headaches can be due to a lack of continuity in the sleep-wake cycle.
C. is correct because cluster headaches occur about the same time every day for 4 to 12 weeks.
E. is correct because a client can have a runny nose and nasal congestion with a cluster headache.
A nurse is caring for a client who has global aphasia (both receptive and expressive aphasia). Which of the following should the nurse include in the client's plan of care? (Select all that apply!)
A. Speak to the client at a slower rate.
B. Assist the client to use flash cards with pictures.
C. Speak to the client in a loud voice.
D. Complete sentences that the client cannot finish.
E. Give instructions one step at a time.
A. B. and E.
A. Clients who has global aphasia have difficulty with peaking and understanding speech. One strategy that can enhance client understanding is speaking to the client at a slow pace.
B. One strategy that can enhance understanding is the use of alternative forms of communications, such as flash cards with pictures or a computer.
E. One strategy that can enhance understanding is giving instructions one step at a time.
Incorrect:
C. For the client with has aphasia, speaking in a loud voice is unnecessary and can be interpreted as patronizing.
D. The nurse should allow the client adequate time to finish sentences and not complete the sentences for the client.
A nurse is teaching a client who has MS and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching?
A. "This medication will help you with your tremors."
B. "This medication will help you with your bladder infection."
C. "This medication may cause your skin to bruise easily."
D. " This medication may cause you to experience weakness."
D. Is correct because Baclofen is an antispasmodic medication that is given to clients who have MS to treat muscle spasms. An adverse effect of this medication is weakness, as well as dizziness. The nurse should instruct the client to monitor for these findings, as they can lead to impaired safety. The client should be instructed not to discontinue baclofen abruptly.
A. Propranolol is a beta blocker and clonazepam is a benzodiazepine given to clients who have MS to treat tremors.
B. Propantheline is an anticholinergic medication that is given to clients who have MS to treat bladder dysfunction.
C. Prednisone is a corticosteriod medication that is given to clients who have MS to treat inflammation. An adverse effect of this medication is bruising of the skin.
A nurse is caring for a client who has Alzheimer's disease. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurse's response? (Select all that apply!)
A. Exposure to metal waste products.
B. Long-term estrogen therapy
C. Sustained use of Vitamin E.
D. Previous head injury.
E. History of herpes infection.
A., D., and E.
B is NOT correct because estrogen therapy can prevent AD.
C is NOT correct because long-term use of vitamin E is NOT a risk factor for AD.
Previous head injury, history of herpes infection, and exposure to metal and toxic waste are risk factors for AD.
To determine whether a new patient's confusion is caused by dementia or delirium, which action should the nurse take?
a. Assess the patient using the Mini-Mental Status Exam.
b. Obtain a list of the medications that the patient usually takes.
c. Determine whether there is positive family history of dementia.
d. Use the Confusion Assessment Method tool to assess the patient.
d. Use the Confusion Assessment Method tool to assess the patient.
The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium.
A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique (Select all that apply!)
A. Place the client in a supine position.
B. Flex client's hip and knee.
C. Place hands behind the client's neck.
D. Bend client's head toward chest.
E. Straighten the client's flexed leg at the knee.
Kernig's sign, Brudzinski's sign, and nuchal rigidity are bedside diagnostic signs used to evaluate suspected cases of meningitis.
A. C. and D. these are all actions to check for Brudzinski's sign.
B. is NOT correct because the nurse should flex the client's hip and knee when assessing for Kernig's sign.
E. The nurse should straighten the client's flexed leg at the knee when assessing for Kernig's sign.