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Text 2 NUR2940 Flashcards | StudBud
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Text 2 NUR2940
Text 2 NUR2940
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1
A TBI client with impaired swallowing is working with speech therapy. What would the nurse assess as a priority goal?
Client eats at least 65% of meals
Client maintains healthy weight
Client has clear lung sounds on auscultation
Client can feed themselves with ease
2
The nurse is preparing a client with cirrhosis for a paracentesis. What is a priority for preparation?
Drawing liver enzymes
Drawing electrolytes
Making sure the client has an empty bladder
Placing the client prone
3
Client with Hx of ETOH abuse presents to ED w/ hematemesis, change in LOC, HR 130, BP 90/60. What interventions?
Administer Octreotide
Administer a benzodiazepine
Obtain blood cultures
Start IV of D5 1/2 NS
4
A client begins to have severe epistaxis after completing a dose of TPA. What should the RN do? (SAA)
Set up suction at the bedside
Assess client mentation
Assess the airway
Red, Blue, and Yellow
5
Client with L-2 spinal injury complains of a throbbing headache and has B/P of 200/99. What is priority intervention?
Perform an ECG
Administer pain medication
Complete a neurological assessment
Palpate the bladder
6
The client is confused, can open eyes to painful stimuli, and follows commands. What is the Glasgow Coma Scale score?
12
4
15
8
7
What education is appropriate for a sickle cell client to help diminish the chance of crisis?
Drink plenty of fluids
Decrease outdoor activities
Learn deep breathing techniques
Eat foods high in iron
8
What should the RN teach a client with cirrhosis prior to discharge?
Take acetaminophen for pain
Following dietary restrictions may help cure cirrhosis
Use a stool softener to avoid constipation
Eat high protein, high carb diet
9
Client with T-3 spinal injury complains of a throbbing headache and has B/P of 200/99. What is priority intervention?
Perform an EKG
Complete a neurological assessment
Palpate the bladder
Administer pain meds
10
What clinical findings support the diagnosis of Systemic Lupus?
Fatigue, butterfly rash, alopecia
Butterfly rash, hair growth, bruising
Bruising, diaphoresis, fatigue
Alopecia, hypertension, bruising
11
Client to ED with L sided weak, worst headache they have experienced & HTN. The CT shows brain bleed. What orders?
Prepare for intra-arterial TPA
IV antihypertensives
Transfusion fresh frozen plasma
IV anticoagulant therapy
12
RN notes that a client with a diffuse axonal injury, has all four limbs rigidly extended. The nurse identifies this as?
Decorticate posturing
Decerebrate posturing
Supermodel posturing
Prone posturing
13
Client has been taking methotrexate for two weeks. Which laboratory data would warrant intervention?
RBC count of 2.5
Hematocrit of 43%
Hemoglobin of 14.5
WBC count of 9,500
14
What medication would be appropriate for client with RA who has severe pain and stiffness in her hands in the morning?
Predisone
Adderal
Aspirin
Prevacid
15
Client has right sided disturbed visual perception related to homonymous hemianopsia? What should the nurse do?
Place objects on the client's left side to assess ability to compensate
Approach the client from left side to encourage the client to turn head
Patch the affected eye to encourage the client to scan the environment
Teach client scanning techniques to visualize the entire visual field
16
What would cause the nurse concern in a client with heart failure?
Client has +1 edema to ankles
Client has gained 1 pound in 5 days
Client is experiencing shortness of breath
Client BP decreased from 190/100 to 160/86 after dose of Metoprolol
17
What would be a possible effect of right sided stroke?
Trouble writing
Depression/anger
Poor impulse control
Aphasia
18
What should the nurse teach a T-7 spinal cord client concerning skin care?
I should not apply lotion to my skin more than 1 time/week
I should refrain from active ROM for my upper extremities
Make sure you maintain a high protein diet
Keep cloths and linens free of wrinkles when lying and sitting
19
Client positive ANA, fever, achy joints, and a rash on nose/cheeks. Which laboratory value requires further assess?
Creatinine 2.5
Platelets 150,000
WBC 9,000
RBC 4.7
20
What should the nurse teach parents of a child with CP about Baclofen
Med may cause urine to turn orange
Med should be given prn
Med may cause drowsiness
Muscle spasms should stop after first dose
21
What would the nurse suspect when he notices a sweet, musty odor from the breath of a client with cirrhosis?
Fetor Hepaticus
Diabetic ketoacidosis
Hepatic encephalopathy
Alcohol intoxication
22
What would be a possible effect of left sided stroke?
Impaired reading ability
Left hemiparesis
Euphoria
Impaired judgement
23
Client w/ elevated ammonia level given lactulose. How will the RN evaluate the med effectiveness?
Vital signs
WBC count
Urine output
Number of bowel movements
24
Which nutrients will help prevent osteoporosis?
Folic Acid and vit D
Calcium and biphosphonates
Biotin and Vit C
Vit B and C
25
Client has CT confirmed ischemic stroke. What would be a absolute contraindication for TPA?
Witnessed symptoms started 2 hours ago
BP on arrival 200/100
GI bleed 14 days ago
Ischemic CVA 3 years ago
26
A child with cerebral palsy tongue moves continually, making feeding hard. Which nursing intervention takes priority?
Consult for speech therapy
Collaborate with dietary
Monitor for signs of aspiration
Apply seizure pads to side rails
27
Nurse knows the client needs more teaching on the effects of hydroxyurea when she states?
Hydroxyurea can cause bone marrow suppression
I need to have my liver enzymes checked every year
I should not get pregnant while taking this medication
Medication should reduce my risk of acute chest syndrome
28
What teaching should the nurse complete about precipitating factors that lead to hypoxemia during Sickle Cell crisis?
Avoid outdoor activities in extreme cold or heat
Make sure you get the flu shot every 3-5 years
If Hgb is less than 8 contact your doctor
You should get lab work done yearly
29
What should be included in teaching for a client with a L-5 compression fracture?
Follow up with speech therapy
Vaccinations should be completed as soon as possible
Change positions slowly
Client will need help with ADLs
30
What would you see with Cushing's triad
Elavated HR
Decreased SpO2
Elevated RR
Elevated BP