NUR 2755 Multidimensional Care IV
MDC IV – Exam 1
The client has presented with a basilar skull fracture. While assessing the client, the nurse notes clear drainage from the nose with a "halo sign" and is concerned about a potential cerebral spinal fluid leakage. What should the nurse do next?
Correct Answer:
Check for the presence of glucose in the drainage and report to the provider
A client has been injured in a motorcycle accident and is presenting with signs and symptoms of increased intracranial pressure. Which would the nurse identify as a very late sign of increased intracranial pressure (ICP)?
Correct Answer:
Abnormal posturing
The nurse understands that ergotamine medications are beneficial in which of the following conditions?
Correct Answer:
Migraine headaches
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The nurse assesses a 27-year-old female client who presents with muscle weakness and decreased muscle coordination over the past few months. What nervous system disease is she most likely suffering from?
Correct Answer:
Myasthenia gravis
The nurse is obtaining a health history for a 45-year-old woman with Guillain- Barré 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 the 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."
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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
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