NUR 2755 Multidimensional Care IV
MDC 4 Exam 1
The nurse is obtaining a health history for a 45-year-old woman with Guillain-Barre syndrome (GBS). Which statement by the client does the nurse correlate with the client's diagnosis?
Correct Answer:
"I just got over the flu a couple of weeks ago, and now this."
A nurse is caring for a client with a closed head injury with intracranial pressure (ICP) readings between 16 and 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.)
Correct Answer:
Decrease the noise in the client's room Administer a stool softener Keep the client well hydrated
A graduate nurse is performing discharge teaching for a client newly diagnosed with migraine headaches. Which statement made by t he graduate nurse indicates a correct understanding of this disorder?
Correct Answer:
"Propranolol is not an abortive migraine medication but used to manage and prevent migraines." 1 / 4
The nurse is educating a client on the types of anesthesia used in surgery.Which client statement indicates a correct understanding?
Correct Answer:
"I am having general anesthesia, so I will be given a gas to breathe and medication in my IV."
Important nursing measures needed when feeding a hemiplegic client include which of the following? (Select all that apply.)
Correct Answer:
Ensure the client is wearing dentures with food intake Thicken all liquids, including water Assess respiratory rate and ease of swallowing
To promote venous return from the lower extremities, appropriate exercises that should be taught to the client include which of the following? (Select all that apply.)
Correct Answer:
Dorsiflex and plantarflex the feet Flex the hip and knee and rotate the lower leg laterally Bend the knees and push the ball of the feet on the bed
A client arrives at the Emergency Department with new-onset slurred speech and weakness. The nurse inquiries when the client was last seen as normal.What priority assessment information does the health care team need to know before a "stroke alert" is initiated?
Correct Answer:
Blood glucose levels 2 / 4
The client has an order for 0.45% sodium chloride 1 liter to infuse over 15 hours. At what rate in ml/hr would the nurse set the infusion pump? (Round to the nearest whole number, do not use a trailing zero. Enter numeric answer only.)
Correct Answer:
67
The Glasgow coma scale is a screening tool used to assess level of consciousness in three major areas. When analyzing a client's score, the nurse identifies the three areas of assessment as which of the following?
Correct Answer:
Eye opening, best motor response, verbal response
The nurse is caring for a client diagnosed with Alzheimer's disease. Which nursing tasks should be delegated to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Correct Answer:
Perform the client's morning hygiene care Ambulate the client to the bathroom Obtain the client's routine vital signs
A client arrives in the emergency department with an ischemic stroke.Because the healthcare team is considering administering tissue plasminogen activator (t-PA), what should the nurse perform first?
Correct Answer:
Identify the time of onset of the stroke
- / 4
A client has been admitted to the neurological department because of seizures of unknown cause. Which of the following is the priority intervention?
Correct Answer:
Ensure suction equipment is available
A client has been diagnosed with organic brain pathology. He is unable to use words or objects correctly. The nurse correctly identifies the signs and symptoms as which of the following?
Correct Answer:
Apraxia
A nurse is assessing a client in postoperative recovery. The client complains of the following symptoms. Which of the following is abnormal and should be reported immediately?
Correct Answer:
Emesis that is red
The nurse is caring for a client with a comminuted fracture of T6-T7, which has resulted in paraplegia. The client manifests signs and symptoms of autonomic dysreflexia triggered by which of these?
Correct Answer:
Bowel distention
- / 4