Which intervention would the nurse include in the pain of care for a client who has late-stage Alzheimer disease (AD)?

Maintain a consistent routine for the clients care

The client’s blood pressure is 86/42 mm Hg.

Which client statement indicates a need for further education about how to manage their osteoarthritis (OA)?

I will take 1 g of acetaminophen every 4 hours

Which question best for the nurse to ask pt who is admitted to emergency room (ER) with the onset of type 1 diabetes?

Have you lost any weight lately

Which information obtained by the nurse indicates that a client is experiencing delirium rather than dementia?

The client was oriented and alert when admitted to hospital

Which assessment data obtained by the nurse during the assessment of a client with cirrhosis is of most concern?

The client’s hands flap back and forth when the arms are extended

The following diet instructions should be included in the plan of care to help a pt control ulcerative colitis symptoms?

Avoid food that trigger your bowel symptoms

The staff nurse suctions the client every 2 hours

What is the major goal of treatment for the client with chronic, progressive neurological disease?

Adaptation by client and family to the disease

Which intervention would be a priority for the nurse to implement for a client following a cholecystectomy?

Turn, cough and deep breath every 2 hours

Which home care instructions should the nurse include for a client with a long-arm cast on the right arm?

Call the physician for increased swelling or numbness

Which action would the nurse take when caring for a head injury client with clear nasal drainage?

Check the nasal drainage for glucose

See photo for question

Place the client on a cardiac monitor

Which information would alert the nurse that screening for hepatitis C should be performed?

The client reports use of intravenous (IV) drugs 20 years ago

Best action for a client with a permanent ileostomy who refuses to look at the stoma?

ask pt more about the concerns with stoma management

The neurological functions that are affected by a stroke are primarily related to?

The brain area perfused by the affected artery

Critical assessment finding to report for GI bleeding client on 500mL/hr NS IV?

The client’s lungs have audible crackles

Which position would the nurse understand would be best for a client with increased intracranial pressure (ICP)?

Elevate the head of the bed 30 degrees

After receiving change of shift report, which of the following clients should the nurse assess first?

A 61-pt who has increased ICP and is receiving hyperventilation therapy

Teaching for type 2 diabetes with sensory neuropathy of the feet and legs?

Assess feet daily for cuts and injuries

Perform range-of-motion (ROM) exercises every 4 hours

Which information would the nurse include in the plan of care for a client whos fasting blood glucose level 6.7mmol/L?

Lifetstyle changes to lower blood glucose

Which action would the nurse undertake when a diabetic client reports feeling anxious, nervous and sweaty?

Obtain a glucose reading finger stick

An 85 is diagnosed with a stroke is complaining of a severe headache. Which intervention should nurse implement first?

Prepare patient for a stat head CT

Which intervention would the nurse include in the plan of care for hospitalized client with moderate dementia?

remind the client frequently about being in the hospital

Which nutritional goal would the primary focus for a client newly diagnosed with type 2 diabetes?

Control of dietary intake to achieve ideal body weight

Which would be most appropriate for the nurse to implement to protect pt from injury during an episode of delirium?

Assign PSW to stay with the client and offer frequent orientation

First diagnostic test for ER admission with right-sided weakness starting 90 minutes ago?

Non-contrast computed tomography (CT) scan

Oral temperature 38.7°C (101.7°F)

Which intervention is the priority for a client in the ER with possible lower left extremity fractures?

Check neurovascular status distal to the injury

nurse is caring 4 a pt who has head injury and diagnosed with a concussion. which following actions should nurs do 1st

Provide discharge instructions about monitoring neurological status.

Which finding indicates that the lactulose treatment for a client with advanced cirrhosis has been effective?

The client is alert and oriented

First action for ER admission of pancreatitis client vomiting blood?

Check blood pressure (BP), heart rate (HR), and respiration (RR)

Best nurse response when a client with bleeding esophageal varices asks about pantoprazole?

The medication will prevent irritation to the esophageal varices

Which client would the nurse identify as being most at risk for experiencing a stroke?

66 year old male, with AF & increased serum cholesterol

Prepare the client for immediate craniotomy

Swab the nasopharyngeal mucosa for cultures

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FINAL TEST Health & Healing IV Practice Questions

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Questions 110

Answers

1
Which intervention would the nurse include in the pain of care for a client who has late-stage Alzheimer disease (AD)?
Maintain a consistent routine for the clients care
Provide the client with current newspapers and magazines
Reorientate the client to the date and time every two hours
Encourage the client to discuss events from the past
2
see photo
The client complains of having a stiff neck.
The client’s blood pressure is 86/42 mm Hg.
The client’s temperature is 38.3°C (100.9°F).
The client has a positive Kernig’s sign.
3
See photo
Schedule CT scan stat
.Notify SLP for a gag assessment
Prepare tPA
.Discuss precipitating risk factors
4
Why is it important to call 9-1-1 immediately if you have a stroke?
A bleeding stroke may require surgery
All the above
Clot medications tPA have to be given within 3- 4.5 hours of symptom onset
The earlier the treatment, the better
5
Which client statement indicates a need for further education about how to manage their osteoarthritis (OA)?
I will take a shower in the morning to help relieve stiffness
I can use a cane to decrease the pressure and pain in my hip
I can take glucosamine to help decrease my knee pain
I will take 1 g of acetaminophen every 4 hours
6
Which question best for the nurse to ask pt who is admitted to emergency room (ER) with the onset of type 1 diabetes?
Have you lost any weight lately
How long have you felt anorexic
Is your urine usually dark coloured.
Do you crave fluids containing sugar
7
Which information obtained by the nurse indicates that a client is experiencing delirium rather than dementia?
The client’s speech is fragmented and incoherent
The client is disorientated to place and time but oriented to person
The client was oriented and alert when admitted to hospital
The client has a history of increasing confusion over several years
8
Which assessment data obtained by the nurse during the assessment of a client with cirrhosis is of most concern?
The client has ascites and a 2kg weight gain from the previous day
The client’s hands flap back and forth when the arms are extended
The client’s skin has multiple spider-shaped blood vessels n the abdomen
The client complains of right upper quadrant pain
9
The following diet instructions should be included in the plan of care to help a pt control ulcerative colitis symptoms?
Avoid fresh fruits and vegs
limit coffee to 6 servings daily
drink milk or eat milk products at least 6 times a day
Avoid food that trigger your bowel symptoms
10
see photo
Decerebrate posturing
Flexion withdrawal
Decorticate posturing
Localization of pain
11
see photo
The staff nurse elevates the head of the bed to 30 degrees
The staff nurse assesses neurological status every hour
The staff nurse suctions the client every 2 hours
The staff nurse administers a mild analgesic before turning the client
12
What is the major goal of treatment for the client with chronic, progressive neurological disease?
Adaptation by client and family to the disease
Continuation of usual life style
Reversal of pathophysiological features
Total remission of the disease
13
Which laboratory results would the nurse report to the healthcare provider when caring for a pt recently had a stroke?
WBC 9.2 x 109/L
pH 7.41
PaO2 96 mmHg
PaCO2 51 mmHg
14
Which intervention would be a priority for the nurse to implement for a client following a cholecystectomy?
Ambulate the evening of the operative day
Client education about low fat food choices.
perform leg exercises hourly while awake
Turn, cough and deep breath every 2 hours
15
Which home care instructions should the nurse include for a client with a long-arm cast on the right arm?
Keep the hand immobile to prevent soft tissue swelling
Keep the right shoulder elevated on a pillow or cushion
Call the physician for increased swelling or numbness
Avoid the use of nonsteroidal anti-inflammatory drugs (NSAID) for 1st 48
16
Next action for peptic ulcer client with NG tube, severe pain, diaphoresis, and firm abdomen?
obtain the vital signs
Listen for bowle sounds
give the ordered antacid
irrigate the ng tube
17
Which action would the nurse take when caring for a head injury client with clear nasal drainage?
Obtain a specimen of the fluid to send for culture and sensitivity
Have the client blow the nose
Check the nasal drainage for glucose
Assure the client that rhinorrhea is normal after a head injury
18
See photo for question
Obtain urine glucose and ketone levels
Place the client on a cardiac monitor
Administerintravenous(IV)potassium supplements
Infuse regular insulin at 20 units/hour
19
Which lab result monitors prednisone effectiveness in acute RA exacerbation?
Liver function tests
C-reactive protein level
Blood glucose test
Serum electrolytes
20
Which information would alert the nurse that screening for hepatitis C should be performed?
The client eats frequent meals in fast-foods restaurants
The client reports use of intravenous (IV) drugs 20 years ago
The client had a blood transfusion after surgery in 2015
The client recently travelled to an underdeveloped country
21
which food products decrease the lower esophageal sphincter (LES) pressure and should be avoided with GERD.
Acidic and pickled foods
Coffee, Tea and Chocolate
Spicy and highly seasoned foods.
rice, bread and pasta
22
Best action for a client with a permanent ileostomy who refuses to look at the stoma?
reassure the client that the care for teh ileostomy will become easier
ask pt more about the concerns with stoma management
Postpone pt teaching until pt adjusts to ileostomy
Develop a detailed written plan for ostomy care
23
The neurological functions that are affected by a stroke are primarily related to?
.The rapidity of onset of symptoms
The presence of absence of collateral circulation
The amount of tissue involved
The brain area perfused by the affected artery
24
Critical assessment finding to report for GI bleeding client on 500mL/hr NS IV?
The nasogastric (NG) suction is returning coffee-ground material
The client’s blood pressure (BP) has increased to 142/94
The bowel sounds are very hyperactive in all four quadrants
The client’s lungs have audible crackles
25
Which position would the nurse understand would be best for a client with increased intracranial pressure (ICP)?
Keep the head of the bed flat
Elevate the head of the bed 30 degrees
Use a continuous-rotation bed
Maintain the client on their left side
26
Indicator of effective NG tube suction and NPO therapy in acute pancreatitis?
electrolyte levels are normal
abdominal pain decreased.
bowel sounds are present
grey turner sign resolves
27
The nurse is caring for pt with increased intracranial pressure (IICP). Which of the following is an early sign of IICP?
Unilateral hemiparesis
Hyperthermia
Decerebrate posturing
Decorticate posturing
28
After receiving change of shift report, which of the following clients should the nurse assess first?
A 61-pt who has increased ICP and is receiving hyperventilation therapy
A 23-year-old who had a skull fracture and craniotomy the previous day
A 44-year-old receiving IV antibiotics for meningococcal meningitis
A 30-year-old who has an intracranial pressure (ICP) monitor in placed.
29
The nurse should assess a 45-year-old with cirrhosis, severe ascites, and an oral temperature of 38.8°C first.
True
False
30
Teaching for type 2 diabetes with sensory neuropathy of the feet and legs?
Soak the feet in warm water for an hour everyday
Assess feet daily for cuts and injuries
Set heating pads on low temperature
buy a callus remover for corns and calluses
31
See photo
Cluster nursing activities to allow longer rest periods
Position the bed flat and log roll the client
Perform range-of-motion (ROM) exercises every 4 hours
Turn and reposition the client side to side every 2 hours
32
Which information would the nurse include in the plan of care for a client whos fasting blood glucose level 6.7mmol/L?
Lifetstyle changes to lower blood glucose
effects of oral hypoglycemic medications
self monitoring of blood glucose
use of low does of reg insulin
33
Which action would the nurse undertake when a diabetic client reports feeling anxious, nervous and sweaty?
have the client eat a chocolate bar
obtain a urine sample for glucose level
Obtain a glucose reading finger stick
administer 1 mg of glucagon subcutaneously
34
An 85 is diagnosed with a stroke is complaining of a severe headache. Which intervention should nurse implement first?
Commence and IV of NS
Administer Tylenol
Complete a neurological assessment
Prepare patient for a stat head CT
35
Which intervention would the nurse include in the plan of care for hospitalized client with moderate dementia?
Reposition the client frequently to avoid skin breakdown
Place suction at the bedside to decrease the risk of aspiration
Provide complete persona hygiene care for the client
remind the client frequently about being in the hospital
36
Which nutritional goal would the primary focus for a client newly diagnosed with type 2 diabetes?
Reduction in dietary calories and fat to normalize glucose,lipids,bp levels
Control of dietary intake to achieve ideal body weight
Maintenance of = distribution of carbohydrate thru the day
Elimination of simple sugars in exchange for complex carbohydrates in diet
37
which assessment information should the nurse collect to determine whether pt is developing post-concussion syndrome
Pupil reaction to light
Glasgow coma scale
Short-term memory
Muscle resistance
38
Which would be most appropriate for the nurse to implement to protect pt from injury during an episode of delirium?
Instruct family members to remain with the client to prevent injury
Secure the client in bed using soft chest restraint
Assign PSW to stay with the client and offer frequent orientation
Ask physician about ordering an antipsychotic drug
39
First diagnostic test for ER admission with right-sided weakness starting 90 minutes ago?
Chest radiograph (CXR)
Complete blood count (CBC)
Electrocardiogram (ECG)
Non-contrast computed tomography (CT) scan
40
see photo
Oral temperature 38.7°C (101.7°F)
Mean arterial pressure 90 mm Hg
Intracranial pressure 15 mm Hg
Apical pulse 102 beats/minute
41
Which intervention is the priority for a client in the ER with possible lower left extremity fractures?
Control external bleeding with direct pressure
Provide adequate pain relief
Check neurovascular status distal to the injury
Treat life threatening injuries first
42
nurse is caring 4 a pt who has head injury and diagnosed with a concussion. which following actions should nurs do 1st
Arrange to admit pt to the neurological unit for observation for 24 hours.
Provide discharge instructions about monitoring neurological status.
Transport pt 2 radiology for magnetic resonance imaging (MRI) of the brain.
Coordinate the transfer of the client to the operating room
43
Most important lab tests to monitor in acute hepatitis?
INR and PTT levels
Potassium level
ALT, ALP, ALK levels
Sodium level
44
Which finding indicates that the lactulose treatment for a client with advanced cirrhosis has been effective?
The client has at least one stool daily
The client denies nausea and anorexia
The client bilirubin level decrease
The client is alert and oriented
45
First action for ER admission of pancreatitis client vomiting blood?
Insert a large-gauge intravenous(IV) catheter
Draw blood for coagulation studies
Pace the client in supine position
Check blood pressure (BP), heart rate (HR), and respiration (RR)
46
Best nurse response when a client with bleeding esophageal varices asks about pantoprazole?
The medication will inhibit the development of gastric ulcers
The medication will prevent irritation to the esophageal varices
The medication will decrease nausea and anorexia
The medication will reduce the risk for aspiration
47
see photo
Oxygen saturation
Blood pressure
Hematocrit
Intracranial pressure
48
Which client would the nurse identify as being most at risk for experiencing a stroke?
65 year old female with hypertension
66 year old male, with AF & increased serum cholesterol
60 year old male with a sedentary lifestyle
45 year old female with hypertension & diabetes
49
Which nursing diagnosis would be a priority for pt an open reduction and internal fixation (ORIF) of a fractured tibia?
Reduced Mobility
Risk of infection
Risk of impaired integrity
Risk for constipation
50
See Photo
Initiate high-dose barbiturate therapy
Type and crossmatch for blood transfusion
Prepare the client for immediate craniotomy
Administer IV furosemide
51
See Photo
Swab the nasopharyngeal mucosa for cultures
e a cooling blanket to lower temperature.
Administer ceftizoxime 1 g IV.
Give acetaminophen 650 mg PO.
52
First intervention for ER client with massive right lower leg swelling after a crash?
Check the leg pulses and sensation
Apply a compression bandage
Place ice packs on the lower leg
Elevate the leg on pillows
53
Key teaching points for a client on clopidogrel (Plavix) for cerebral atherosclerosis?
Monitor and record the blood pressure(BP) daily
it will dissolve clots in teh cerebral arteries
it will reduce cerebral artery plaque formation
Call the physician is stools are tarry
54
see photo
Draw blood for arterial blood gases (ABGs).
Send client for computed tomography (CT) of the head.
Administer acetaminophen 650 mg orally.
Administer 5% hypertonic saline intravenously.
55
Highest priority action for cirrhosis client with massive esophageal variceal hemorrhage?
Relief of the patient’s anxiety
Maintenance of fluid volume
Control of the bleeding
Maintenance of the airway
56
See photo
Apply soft restraints to protect the client from injury
Minimize contact with the client to decrease sensory input.
Encourage family members to remain at the bedside
Keep the room well lighted to improve client orientation.
57
Which risk factor would be most important for the nurse t address to decrease the risk of stroke?
The client's blood pressure is usually about 9080 mmHG
The client's blood pressure is usually about 90/40 mmHG
The client's blood pressure is usually about 70/60 mmHG
The client's blood pressure is usually about 180/90 mmHG
58
Which explanation would the nurse provide a pt with Parkinson’s disease (PD) about the possible causes of constipation?
Diminished nerve conduction to the bowel
Decreased physical activity
Side-effects of dopaminergic agents
Advanced age
59
Which test would nurse plan for the pt scheduled a follow-up visit in the clinic to evaluate the effectiveness 4 type2
oral glucose tolerance test
fasting blood glucose level
Glycated hemoglobin test
A urine dipstick for glucose
60
pt with a head injury. Which of the following findings should be reported rapidly to the health care provider?
Intracranial pressure of 16 mm Hg when client is turned
Ventriculostomy drains 10 mL of cerebro-spinal fluid per hour
Urine output of 800 mL in the last hour
LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
61
Which response by the nurse is best when a client asks about what to expect in the future with crohn’s disease?
you can lead a normal life with no syptoms
The disease is unpredictable with period of recurrence and remission
Most clients with Crohn's disease require an ileostomy
There is high risk for colon cancer unless you have colon removed
62
Which action should the nurse take first for pt with a fractured hip in skeletal traction who develops acute confusion?
Assess the oxygen saturation
Check pupil reaction to light
Assess client orientation
Take the blood pressure (BP)
63
Which information would the nurse explain to a husband of a woman who is being evaluated for Alzheimer ‘s disease (AD)
AD is diagnosed only after ruling out other causes of dementia.
The most important risk factor AD is a family history of the disorder
presence of brain atrophy and enlarged ventricles confirms diagnosis of AD
New drugs, such as donepezil (Aricept), have shown to quickly reverse AD
64
Which would be the most beneficial in the treatment plan for an obese client with bilateral osteoarthritis of the hips?
Use a wheelchair to avoid walking as much as possible
Sit in chairs that do not cause his hips to be lower than his knees
Use a walker for ambulation to relieve the pressure on his hips
Use the weight-reduction diet to obtain a healthy body weight
65
time most important for nurse to monitor for symptoms of hypoglycemia after administering aspart insulin at 0800 hours?
0830 hours
2000 hours
1600 hours
0900 hours
66
See photo
Assess the incision for redness
Check the client’s blood pressure (BP)
Notify the physician
Reposition the left leg on pillows
67
see photo
Apply cold packs for facial bruising
Turn client every 2 hours
Keep the head of bed elevated
Insert nasogastric tube
68
Nurse's response when a TIA client refuses daily aspirin, thinking it's for pain?
Tell the client that the aspirin is used to prevent aches and pains
Explain that the aspirin is ordered to reduce the risk of stroke
Call the healthcare provider to clarify the medication order
Document that the aspirin was refused by the client
69
A pt is experiencing motor loss as result of a left sided stroke. What clinical manifestation would the nurse observe?
right sided hemiparesis
TIA
Left Sided hemiparesis
Left sided neglect
70
Which question would the nurse ask the client to determine the possible risk factors for blood-streamed vomit?
History of recent weight gain or loss
Any family history of gastric problems
The amount of fat in the diet
use of nonsteroididal anti-inflammatory drugs (NSAIDs)
71
Which discharge statement from a head injury patient requires nurse intervention?
I am going to drive home and go to bed
I will return if I feel dizzy or nauseated
I can take acetaminophen for my headache
Do not even remember being in an accident
72
Which procedure would the nurse anticipate for pt admitted to emergency room (ER) with vomiting of coffee-ground emesis?
Angiography
Endoscopy
Barium contrast studies
Gastric analysis testing
73
Which intervention should the nurse include in the teaching plan for an MS pt worried about exacerbations and fatigue?
Limit activities and take morning and afternoon naps
Space activities throughout the day with opportunities for rest
Identify where assistive devices can be obtained
Ask client’s mother to help with the children in the evening
74
See photo
The client indicates a headache at pain level 5 of a 10-point scale.
The client’s blood pressure increases from 120/54 to 136/62 mm Hg.
The client’s pulse is slightly irregular.
The client is more difficult to arouse
75
see photo
Call the family’s pastor or spiritual advisor to support them given.
Ask family stay in the waiting room until the initial assessment is done.
the family members to the hospital counselling service to deal with anxiety
Allow the family to stay with the client and briefly explain all procedures
76
See photo for question ?
Check the client’s blood glucose at 0300 hours
Administer a larger dose of long-acting insulin
Educate the need to increase the rapid-acting insulin dose
Remind the client about the need to avoid snacking at bedtime
77
Which symptoms are the hallmark of delirium?
Disorganized thinking, insidious onset, inattention and altered LOC
Acute onset, fluctuating course, memory loss,altered level of consciousness
Inattention, fluctuating course, hyperactivity, and altered LOC
Slow onset, predictable course, memory loss, and altered LOC
78
Which assessment finding is most critical to report for a client using naproxen for 3 weeks to treat osteoarthritis?
The client’s pain has not improved
The client is using capsaicin cream
The client has gained 3 pounds over 3 weeks
The client has dark-colored stools
79
See Photo for question
Administer insulin by sliding scale as ordered
Advise the pt to eat all of his supper
Ensure the pt recieves a bedtime snack
Obtain a glucose reading before bedtime
80
First intervention for RLQ pain, nausea, vomiting, and 90% O₂ sat?
Asess for abdominal rebound tenderness
Assist the client to deep breathe and cough
Encourage the pt to take sips of clear liquids
Administer oxygen via nasal cannula
81
Which action would the nurse take to determine whether a new client’s confusion is caused by dementia or delirium?
Use the confusion assessment method (CAM) tool to assess the client
Assess the client using the mini-mental status exam
Determine whether there is positive family history of dementia
Obtain a list of the medications that the client usually takes
82
Frequent assessment for unconscious stroke client with GERD?
Apical pulse
Breath Sounds
Bowel Sounds
Abdominal girth
83
Highest priority nursing diagnosis for a stroke client with worsening weakness and decreased LOC?
Risk for injury as evidenced by alteration in cognitive function
Risk for impaired skin integrity as evidenced pressure over bony prominence
Impaired physical mobility related to decreased muscle strength
Risk for aspiration as evidenced by impaired ability to swallow
84
see photo
Document the increase in intracranial pressure
Assure that the client’s neck is not in a flexed position
Notify the health care provider about the change in pressure
Increase the rate of the prescribed propofol infusion
85
What is the priority intervention for a client experiencing nighttime hypoglycemia?
Insert a large bore IV catheter
Initiate oxygen by nasal cannula
Give 50% dextrose bolus
Administer Lantus insulin
86
What is the correct nurse's response to a client asking what is type 2 diabetes?
insulin is not used to control blood glucosein client with type 2 diabetes
Type 2 is usually diagnosed when client is admitted with hyperglycemic coma
changes in diet and exercise may be sufficient to control blood glucose
Complications of type 2 diabetes are less serious then type 1 diabetes
87
Early immobilization and minimal movement of the affected limb.
Administration of prophylactic anticoagulants
Careful immobilization of the fracture site
Coughing and deep breathing q2h
Prevention of hypovolemic shock
88
Which time frame would the nurse inform the client to continue to monitor for post concussion syndrome?
Up to 4 weeks
up to two weeks
up to 6 months
up to 2 months
89
see photo
Right-sided weakness
Difficulty swallowing
Judgement changes
Expressive aphasia
90
Which finding should the nurse report immediately for a client admitted to the ER after falling on the right hip and leg
The client is complaining of leg and hip pain
The right leg appears to be shorter than the left
There is bruising at the hip area
There is decreased range f motion (ROM) of the leg
91
See Photo for question
Time the morning insulin injection so that the peak occurs while swimming
Check the glucose level before, during and after swimming
Delay the noon meal until after swimming
Increase the dose of NPH insulin
92
see photo
CPP 38 mm Hg
MAP 92 mm Hg
PaO2 110 mm Hg
BP 140/82
93
See photo
monitoring system has multiple benefits facilitation of cerebro-spinal
This monitoring system is complex and highly skilled staff are needed
monitoring system helps show whether blood flow to the brain is adequate
monitoring system helps check alterations in cerebral perfusion pressure
94
Which system is a priority for a client who has had a stroke in the acute phase of care?
Gastrointestinal system
Genitourinary system
Respiratory System
Neurological System
95
Which expected finding would the nurse observe in a pt moderate Alzheimer's disease prescribed risperidone (Risperdal)?
Enhanced functional abilities
Stabilization of mood and sleep patterns
Less agitation and aggression
Improved memory and judgement
96
See Photo
84 mm Hg
66 mm Hg
72 mm Hg
58 mm Hg
97
Most critical finding to report for acute cholecystitis admission?
the client has an incfrease in pain after eating
The client’s stools are clay coloured
The client’s urine is bright yellow
the client complains of chronic heartburn
98
Which nursing intervention is appropriate for a client with Alzheimer's disease and impaired memory due to dementia?
Provide pt with as much info as soon as possible to prevent complication o
Inform the client about socially appropriate behaviours
Maintain familiar routines of sleep, meals , drug administration,activities
At every encounter with pt ask the day, time place to promote orientation?
99
First provider order to implement for dehydration and hypotension after 3 days of nausea and vomiting?
Infuse normal saline (NS) at 250mL/hour
Provide oral mouth care
Administer IV ondansetron (Zofran)
Insert nasogastric (NG) tube
100
Which neurological assessment finding would the nurse find in a client with diagnosis of Parkinson’s disease (PD)?
Droopy eyelids
An intention tremor
A shuffling a d propulsive gait
Impaired mental acuity
101
Which action would the nurse take first when admitting a pt with left-sided hemiparesis in the emergency room (ER) unit?
Send the client for a CT scan
Monitor the blood pressure
Check respiratory rate
Obtain the Glascow Coma Scale (GCS)
102
Expected procedure for a TIA client with new hemiparesis and dysarthria within 2 hours?
Intravenous infusion of heparin
Administration aspirin
Surgical endarterectomy
Tissue plasminogen activator (tPA) infusion
103
Which practice would be the nurse understand that the client’s traction is being maintained continuously?
Required amount of weight has been applied
The client has no complain of pain
The client’s position is at the top of the bed
Weights are moving freely and the patient is in the correct position
104
Most important teaching topic for young adult with early alcoholic cirrhosis?
treatment with lactulose
need to abstain from alcohol
use vitamin b supplements
maintenance of a nutrition diet
105
see photo
9
15
11
13
106
Which clinical finding would the nurse recognize that the client has ulcerative colitis rather than crohn’s disease?
weight loss
Bloody diarrhea
Abdominal pain and cramping
onset of the disease at age 20
107
Which action should the nurse take while a long-term plaster cast on a fractured left radius is drying?
Cover the case with a small blanket to absorb the dampness
Place the gauze around the cast edge to pad any roughness
Keep the left arm in the dependent position
Handle the cast with the palms of the hands
108
Which of the following assessment pt who was admitted the previous day with a basilar skull fracture is most important?
Temperature of 38.6°C (101.5°F)
Bruising under both eyes
Complaint of severe headache
Large ecchymosis behind one ear
109
Which intervention is essential for an unconscious client with ineffective cerebral tissue perfusion?
Position the client with the knees and hips fixed
Encourage coughing and deep breathing to improve oxygenation
Keep the head of the bed elevated to 30 degrees
Cluster nursing intervention to provide uninterrupted rest periods
110
What is the major goal of treatment for a client with dementia?
Return the client to a higher level of self-carea.
Maintain or increase body weight
Enhance functional ability over time
Maintain the client’s safety

FINAL TEST Health & Healing IV Practice Questions Flashcards | StudBud