CVA
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about
a. Cerebral aneurysm clipping.
b. Heparin intravenous infusion.
c. Oral low-dose aspirin therapy.
d. Tissue plasminogen activator (tPA).
c. Oral low-dose aspirin therapy.
Rationale:
The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
A client diagnosed with widespread lung cancer asks the nurse why he must be careful to avoid crowds and people who are ill. What is the nurse's best response?
A. "With lung cancer, you are more likely to develop pneumonia and could pass this on to other people who are already ill."
B. "When lung cancer is in the bones, it becomes a bone marrow malignancy, which stops producing immune system cells."
C. "The large amount of mucus produced by the cancer cells is a good breeding ground for bacteria and other microorganisms."
D. "When lung cancer is in the bones, it can prevent production of immune system cells, making you less resistant to infection."
D. "When lung cancer is in the bones, it can prevent production of immune system cells, making you less resistant to infection."
Rationale: Tumor cells that enter the bone marrow reduce the production of healthy white blood cells (WBCs), which are needed for normal immune function. Therefore clients who have cancer, especially leukemia, are at an increased risk for infection. Other people are not at risk for becoming infected as a result of contact with a person who has lung cancer. Lung cancer that has spread to the bone is still lung cancer; it is not a bone marrow malignancy. It is true that the person with lung cancer may produce more mucus, which can harbor microorganisms, but this is not the main reason why the client should avoid crowds and people who are ill.
What does the nurse expect to find in a patient with syndrome of inappropriate antidiuretic hormone? Select all that apply.
A. Low blood osmolality
B. Increased serum osmolality
C. Low urine specific gravity
D. Hyponatremia
E. Decreased urine output
A. Low blood osmolality
D. Hyponatremia
E. Decreased urine output
An 80-year-old patient is receiving palliative care for heart failure. What are the primary purposes of her receiving palliative care? Select all that apply
A. Improve her quality of life.
B. Assess her coping ability with disease.
C. Have time to teach patient and family about disease.
D. Focus on reducing the severity of disease symptoms.
E. Provide care that the family is unwilling or unable to give.
A. Improve her quality of life.
D. Focus on reducing the severity of disease symptoms.
Rationale: The focus of palliative care is to reduce the severity of disease symptoms. The goals of palliative care are to prevent and relieve suffering and to improve quality of life for patients with serious, life-limiting illnesses.
The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?
A) The stoma extends 1/2 in. above the abdomen.
B) The skin under the appliance looks red briefly after removing the appliance.
C) The stoma color is a deep red-purple.
D) An ascending colostomy delivers liquid feces.
C) The stoma color is a deep red-purple.
Rationale: An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink/red for a while after the adhesive is pulled off. Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma.
A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions
d. Difficulty comprehending instructions
Rationale:Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
Which action is most important for the nurse to implement to prevent nausea and vomiting in a client who is prescribed to receive the first round of IV chemotherapy?
A. Keep the client NPO during the time chemotherapy is infusing.
B. Administer antiemetic drugs before administering chemotherapy.
C. Ensure that the chemotherapy is infused over a 4- to 6-hour period.
D. Assess the client for manifestations of dehydration hourly during the infusion period.
B. Administer antiemetic drugs before administering chemotherapy.
Rationale: When emetogenic chemotherapy drugs are prescribed, the client should receive antiemetic drugs before the chemotherapy drugs are administered. This allows time for prevention of chemotherapy-associated nausea and vomiting; however, the antiemetic therapy cannot stop until all risks for nausea and vomiting have passed. Clients become nauseated and vomit even if they are NPO.
Which finding should the nurse expect while assessing a client with sepsis? (Select all that apply.)
A) Hypertension
B) Bradycardia
C) Leukocytosis
D) Confusion
E) Tachypnea
C) Leukocytosis
D) Confusion
E) Tachypnea
Rationale: Clinical manifestations of sepsis include mental status changes such as confusion, tachypnea, and either leukocytosis or leukopenia. The client will have hypotension as fluid leaves the intravascular space. The client will experience tachycardia, not bradycardia.
What is the primary purpose of hospice?
A. Allow patients to die at home.
B. Provide better quality of care than the family can.
C. Coordinate care for dying patients and their families.
D. Provide comfort and support for dying patients and their families.
D. Provide comfort and support for dying patients and their families.
Rationale: Provide comfort and support for dying patients and their families.
Hospice provides support and care at the end of life to help patients live as fully and as comfortably as possible. The emphasis is on symptom management, advance care planning, spiritual care, and family support, including bereavement.
The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take?
A) Call the health care provider
B) Place the tube in a bottle of sterile water
C) Immediately replace the chest tube system
D) Place a sterile dressing over the disconnection site
B) Place the tube in a bottle of sterile water
Rationale: If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection.
A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for
A) surgical endarterectomy.
B) transluminal angioplasty.
C) intravenous heparin administration.
D) tissue plasminogen activator (tPA) infusion.
D) tissue plasminogen activator (tPA) infusion.
Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
What are early signs and symptoms of someone developing lung cancer? Select all that apply
A) Persistent productive cough
B) Hemoptysis
C) Hoarseness in voice
D) Dysphagia
E) Overactive clotting
A) Persistent productive cough
B) Hemoptysis
C) Hoarseness in voice
D) Dysphagia
The nurse caring for a client diagnosed with urosepsis finds spider angiomas of the extremities and cool fingertips. The healthcare provider suspects disseminated intravascular coagulation (DIC). Which collaborative intervention should the nurse implement?
A) Administer insulin
B) Administer FFP
C) Decrease IV fluids
D) Give TPN
B) Administer FFP
Rationale: A client with DIC is bleeding and clotting at the same time. Therefore, to control the bleeding, the healthcare provider would prescribe fresh frozen plasma, which contains clotting factors. Insulin is used to manage blood glucose levels in clients with diabetes. The client would receive IV fluids at a higher rate to compensate for fluid shifts. Total parenteral nutrition is used to treat malnutrition, not DIC.
A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." The nurse will document this as
A) somatic pain.
B) referred pain.
C) neuropathic pain.
D) breakthrough pain.
D) breakthrough pain.
Rationale: Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.
The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply.
A) Excessive bubbling in the water seal chamber
B) Vigorous bubbling in the suction control chamber
C) Drainage system maintained below the client's chest
D) 50 mL of drainage in the drainage collection chamber
E) Occlusive dressing in place over the chest tube insertion site
F) Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
C) Drainage system maintained below the client's chest
D) 50 mL of drainage in the drainage collection chamber
E) Occlusive dressing in place over the chest tube insertion site
F) Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has re expanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100mL/hour is considered excessive and requires health care provider notification. The chest tube insertion site is covered with an occlusive (air-tight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.
A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol?
A) Obtain computed tomography (CT) scan without contrast.
B) Infuse tissue plasminogen activator (tPA).
C) Administer oxygen to keep O2 saturation >95%.
D) Use National Institute of Health Stroke Scale (NIHSS) to assess patient.
C)Administer oxygen to keep O2 saturation >95%.
D) Use National Institute of Health Stroke Scale (NIHSS) to assess patient.
A) Obtain computed tomography (CT) scan without contrast.
B) Infuse tissue plasminogen activator (tPA).
Rationale: The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
The nurse is conducting a community health education class on diet and cancer risk reduction. What should be included in the discussion? Select all the apply.
A. Limit sodium intake.
B. Avoid beef and processed meats.
C. Increase consumption of whole grains.
D. Eat "colorful fruits and vegetables," including greens.
E. Avoid gas-producing vegetables such as cabbage.
B. Avoid beef and processed meats.
C. Increase consumption of whole grains.
D. Eat "colorful fruits and vegetables," including greens.
E. Avoid gas-producing vegetables such as cabbage.
Eating cruciferous vegetables such as broccoli, cauliflower, brussels sprouts, and cabbage may reduce cancer risk.
A patient has been receiving chemotherapy and radiation for a diagnosis of non-Hodgkin's lymphoma. In your morning assessment you notice the patient has new onset facial edema, distention of head and neck veins, and dyspnea. Which oncologic emergency would be suspected?
a. Hypercalcemia
b. Spinal Cord Compression
c. Superior Vena Cava Syndrome (SVCS)
d. Tumor Lysis Syndrome (TLS)
c. Superior Vena Cava Syndrome (SVCS)
A patient with chronic cancer pain is receiving imipramine (Tofranil) in addition to long-acting morphine for pain control. Which information is the best indicator that the imipramine is effective?
A) The patient sleeps 8 hours every night.
B) The patient has no symptoms of anxiety.
C) The patient states, "I feel much less depressed since I've been taking the imipramine."
D) The patient states, "The pain is manageable, and I can accomplish my desired activities.
D) The patient states, "The pain is manageable, and I can accomplish my desired activities.
Rationale: Imipramine is being used in this patient to manage chronic pain and improve functional ability. Although the medication also is prescribed for patients with depression, insomnia, and anxiety, the evaluation for this patient is based on improved pain control and activity level.
A nurse is caring for a female client after a bronchoscopy and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians?
a. Dry cough
b. Hematuria
c. Bronchospasm
d. Blood-streaked sputum
c. Bronchospasm
Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours.
Frank blood indicates hemorrhage. A dry cough may be expected.
The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient?
a. Impaired physical mobility related to weakness
b. Disturbed sensory perception related to brain injury
c. Risk for impaired skin integrity related to immobility
d. Risk for aspiration related to inability to protect airway
d. Risk for aspiration related to inability to protect airway
Rationale: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.
A client being treated for advanced breast cancer with chemotherapy reports that she must be allergic to one of her drugs because her entire face is swollen. What assessment does the nurse perform?
A. Asks whether the client has other known allergies
B. Checks the capillary refill on fingernails bilaterally
C. Examines the client's neck and chest for edema and engorged veins
D. Compares blood pressure measured in the right arm with that in the left arm
C. Examines the client's neck and chest for edema and engorged veins
Rationale: The client's swollen face indicates possible superior vena cava syndrome, which is an oncologic emergency. Manifestations result from the blockage of venous return from the head, neck, and upper trunk. Early manifestations occur when the client arises after a night's sleep and include edema of the face, especially around the eyes, and tightness of the shirt or blouse collar. As the compression worsens, the client develops engorged blood vessels and erythema of the upper body, edema in the arms and hands, dyspnea, and epistaxis. Interventions at this stage are more likely to be successful. Late manifestations include hemorrhage, cyanosis, mental status changes, decreased cardiac output, and hypotension. Death results if compression is not relieved.
A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?
A) Give the patient the prescribed PRN opioid.
B) Assess for sensation and strength in the legs.
C) Notify the health care provider about the symptoms.
D) Teach the patient how to use relaxation to reduce pain.
B) Assess for sensation and strength in the legs.
Rationale: Spinal cord compression, an oncologic emergency, can occur with invasion of tumor into the epidural space. The nurse will need to assess the patient further for symptoms such as decreased leg sensation and strength and then notify the health care provider. Administration of opioids or use of relaxation may be appropriate but only after the nurse has assessed for possible spinal cord compression.
One of the most common distinctions of pain is whether it is acute or chronic. Which examples describe chronic pain? Select all that apply.
A) A patient is receiving chemotherapy for bladder cancer.
B) An adolescent is admitted to the hospital for an appendectomy.
C) A patient is experiencing a ruptured aneurysm.
D) A patient who has fibromyalgia requests pain medication.
E) A patient has back pain related to an accident that occurred last year.
F) A patient is experiencing pain from second-degree burns.
A) A patient is receiving chemotherapy for bladder cancer.
D) A patient who has fibromyalgia requests pain medication.
E) A patient has back pain related to an accident that occurred last year.
A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse?
A. Abscess
B. Pneumonia
C. Pneumothorax
D. Pulmonary embolism
C) Pneumothorax
Rationale: A pneumothorax would be the complication of thoracentesis that causes the greatest concern, along with these symptoms.