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NSG 233 Med Surg 3 Exam 2 2023 Questions and Answers (Verified Answers) 1.While admitting a 42-yr-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?A.The patient takes warfarin (Coumadin) daily.B.The patient's blood pressure is 162/94 mm Hg.C.The patient is unable to remember the accident.D.The patient complains of a severe dull headache. ANS A. The patient takes war- farin (Coumadin) daily.The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.
2.A patient in the clinic reports a recent episode of dysphasia and left- sided weakness at home that resolved after 2 hours. The nurse will anticipate teach- ing the patient about 1 / 4
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A.tPA.B.aspirin.C.warfarin (Coumadin) D.nimodipine ANS B. aspirin.After a transient ischemic attack, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodip- ine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
3.A 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 ANS D. Difficulty comprehending instruc- tions Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with 2 / 4
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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.
4.A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care?A.Apply intermittent pneumatic compression stockings.B.Assist to dangle on edge of bed and assess for dizziness.C.Encourage patient to cough and deep breathe every 4 hours.D.Insert an oropharyngeal airway to prevent airway obstruction. ANS A.Apply intermittent pneumatic compression stockings.The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism. Activities such as coughing and sitting up that might increase intracranial pressure or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
5.When obtaining a health history and physical assessment for a 36-yr- old female patient with possible multiple sclerosis (MS), the nurse should A.assess for the presence of chest pain.B.inquire about urinary tract problems.C.inspect the skin for rashes or discoloration. 3 / 4
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D.ask the patient about any increase in libido. ANS B. inquire about urinary tract problems.Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.
6.Which action will help the nurse determine whether a new patient's confu- sion is caused by dementia or delirium?A.Ask about a family history of dementia.B.Administer the Mini-Mental Status Exam.C.Use the Confusion Assessment Method tool.D.Obtain a list of the patient's usual medications. ANS C. Use the Confusion Assess- ment Method tool.The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk
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