Fours for fucking whoreeeeeeeesssss Flashcards
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min
ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the
vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This
results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even
when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the
low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate
for long, and decreased oxygenation and cool, clammy skin will occur later.
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse
expect to find?
a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 beats/min to 80 beats/min
ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight)
response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing
ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will
drop because of decreased HR.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the
greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma
b. A 32-year-old Asian-American man with colorectal cancer
c. A 45-year-old American Indian woman with diabetes mellitus
d. A 53-year-old postmenopausal woman who is on hormone therapy
ANS: C
The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or
Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of
any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular
disease
A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48
beats/min. Which action should the nurse take first?
a. Document the finding in the chart. b. Initiate external pacing. c. Assess the clients medications. d. Administer 1 mg of atropine.
ANS: C
Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The
nurse should check the medication reconciliation for medications that might cause such a drop in heart rate,
then should inform the health care provider. Documentation is important, but it is not the priority action. The
heart rate is not low enough for atropine or an external pacemaker to be needed.
An emergency room nurse obtains the health history of a client. Which statement by the client should alert
the nurse to the occurrence of heart failure?
a. I get short of breath when I climb stairs. b. I see halos floating around my head. c. I have trouble remembering things. d. I have lost weight over the past month.
ANS: A
Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair
climbing. The other findings are not specific to early occurrence of heart failure.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by
the client should alert the nurse to the presence of edema?
a. I wake up to go to the bathroom at night. b. My shoes fit tighter by the end of the day. c. I seem to be feeling more anxious lately. d. I drink at least eight glasses of water a day
ANS: B
Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse
should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm
ANS: C
In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by
poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the
myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or
confusion caused by decreased perfusion.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that
the left pedal pulse is weak. Which action should the nurse take?
a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as left pedal pulse of +1/4.
ANS: C
Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The
pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be
compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and
temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment
data are acquired, the primary health care provider should be notified. Simply documenting the findings is
inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to
the distal portion of the leg. Increasing intravenous fluids will not address the clients problem.
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg
ANS: C
A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in
neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake
decreases, a client can become dehydrated because of dye excretion. The second intervention would be to
increase the clients fluid status. Neurologic changes would take priority.
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Clients level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents
ANS: D
Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing
preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine
based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the
nurse to assess anxiety, mobility, and baseline cardiac status.
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients
health history includes a previous myocardial infarction and pacemaker implantation. Which action should the
nurse take?
a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI.
ANS: B
The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider
and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not
need an electrocardiogram, cardiac enzymes, or increased fluids.
A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery
pressure reading is 25/12 mm Hg. Which action should the nurse take first?
a. Compare the results with previous pulmonary artery pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the health care provider of the elevated pressures. d. Document the finding in the clients chart as the only action.
ANS: A
Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for
diastolic. Although this clients readings are within normal limits, the nurse needs to assess any trends that may
indicate a need for medical treatment to prevent complications. There is no need to increase intravenous fluids
or notify the provider.
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for
bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for
surgery?
a. Administration of IV furosemide (Lasix)
b. Initiation of an external pacemaker
c. Assistance with endotracheal intubation
d. Placement of central venous access
ANS: B
The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the
atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes
the RCA, the AV node would not function and the client would go into heart block, so emergency pacing
should be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node malfunction.
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary
artery disease. Which statement related to nutrition should the nurse include in this clients teaching?
a. The best way to lose weight is a high-protein, low-carbohydrate diet. b. You should balance weight loss with consuming necessary nutrients. c. A nutritionist will provide you with information about your new diet. d. If you exercise more frequently, you wont need to change your diet.
ANS: B
Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat
obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined
whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high
in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition
education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both
important components in reducing cardiovascular risk.
A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at
night. How should the nurse respond?
a. I will consult the provider to prescribe a sleep study to determine the problem. b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help. c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night. d. Use pillows to elevate your head and chest while you are sleeping.
ANS: D
The client is experiencing orthopnea (shortness of breath while lying flat). The nurse should teach the client to
elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this
client. Oxygen and CPAP will not help a client with orthopnea.
A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to
stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond?
a. Chili is high in fat and calories; it would be a good idea to stop eating it. b. The provider has prescribed an antacid for you to take every morning. c. What do you understand about what happened to you?
d. When did you start experiencing this indigestion?
ANS: C
Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The
nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other
responses do not address the clients misconception about recent pain and the cause of that pain.
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?
a. This is a routine surgery and the risk of death is very low. b. Would you like to speak with a chaplain prior to surgery?
c. Tell me more about your concerns about the surgery. d. What support systems do you have to assist you?
ANS: C
The nurse should discuss the clients feelings and concerns related to the surgery. The nurse should not provide
false hope or push the clients concerns off on the chaplain. The nurse should address support systems after
addressing the clients current issue.
An emergency department nurse triages clients who present with chest discomfort. Which client should the
nurse plan to assess first?
a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers
b. A 49-year-old male who reports moderate pain that is worse on inspiration
c. A 53-year-old female who reports substernal pain that radiates to her abdomen
d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
ANS: D
All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen
first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal
pain that spreads through the clients chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the
fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary
problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially
when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a
myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be
seen, they are not a higher priority than myocardial infarction.
A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart
tones heard?
(Click the media button to hear the audio clip.)
a. Administer a diuretic. b. Document the finding. c. Decrease the IV flow rate. d. Evaluate the clients medications.
ANS: B
The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened
ventricle. The nurse should document the finding, but no other intervention is needed at this time.
A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below
should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?
a. Location A
b. Location B
c. Location C
d. Location D
ANS: A
The aortic valve is auscultated in the second intercostal space just to the right of the sternum.
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac
catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.)
a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic.
f. Insert a central venous catheter.
ANS: A, B, C
If the client has kidney disease (as indicated by BUN and creatinine results), fluids and Mucomyst may be
given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to
iodine, including shellfish; the contrast medium used during the catheterization contains iodine. A Foley
catheter and central venous catheter are not required for the procedure and would only increase the clients risk
for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization
An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to
request a prescription for an electrocardiogram? (Select all that apply.)
a. Hypertension
b. Fatigue despite adequate rest
c. Indigestion
d. Abdominal pain
e. Shortness of breath
ANS: B, C, E
Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They
often present with a triad of symptomsindigestion or feeling of abdominal fullness, feeling of chronic fatigue
despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and
therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary
syndrome
A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in
the first few hours after the procedure require immediate action by the nurse? (Select all that apply.)
a. Blood pressure of 140/88 mm Hg
b. Serum potassium of 2.9 mEq/L
c. Warmth and redness at the site
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor
ANS: B, D, E
In the first few hours postprocedure, the nurse monitors for complications such as bleeding from the insertion
site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The clients blood
pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate
an infection, but this would not be present in the first few hours.
A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of
atherosclerosis? (Select all that apply.)
a. Total cholesterol: 280 mg/dL
b. High-density lipoprotein cholesterol: 50 mg/dL
c. Triglycerides: 200 mg/dL
d. Serum albumin: 4 g/dL
e. Low-density lipoprotein cholesterol: 160 mg/dL
ANS: A, C, E
A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density
lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density
lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed
for atherosclerosis.
A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take
when preparing this client for the procedure? (Select all that apply.)
a. Assist the provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the clients prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.
ANS: B, D, E
Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous
blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education
about dobutamine, which will be administered during the procedure, should be performed. Beta blockers are
often held prior to the procedure.
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which
complications of this procedure should the nurse assess? (Select all that apply.)
a. Thrombophlebitis
b. Stroke
c. Pulmonary embolism
d. Myocardial infarction
e. Cardiac tamponade
ANS: A, C, E
Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and
vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke and
myocardial infarction are complications of left-sided heart catheterizations.
A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded
by a P wave. How should the nurse interpret this observation?
a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The clients chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different
ANS: D
Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated
at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of
depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular
tachycardia, or disconnection of leads.
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which
activity modification should the nurse suggest to avoid further slowing of the heart rate?
a. Make certain that your bath water is warm. b. Avoid straining while having a bowel movement. c. Limit your intake of caffeinated drinks to one a day. d. Avoid strenuous exercise such as running.
ANS: B
Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the
vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has
bradycardia. The other instructions are not appropriate for this condition.
A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at
greatest risk for atrial fibrillation?
a. A 45-year-old who takes an aspirin daily
b. A 50-year-old who is post coronary artery bypass graft surgery
c. A 78-year-old who had a carotid endarterectomy
d. An 80-year-old with chronic obstructive pulmonary disease
ANS: B
Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary
artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility
of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity
ANS: B
Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in
mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid
ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have
dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the
nurse expect to find on this clients medication administration record to prevent a common complication of this
condition?
a. Sotalol (Betapace)
b. Warfarin (Coumadin)
c. Atropine (Sal-Tropine)
d. Lidocaine (Xylocaine)
ANS: B
Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with
anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for
this complication.
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess
for as the expected therapeutic response?
a. Decreased intraocular pressure
b. Increased heart rate
c. Short period of asystole
d. Hypertensive crisis
ANS: C
Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and
chest pain. Adenosine has no conclusive impact on intraocular pressure.
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart
rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?
a. Pulmonary auscultation
b. Pulse strength and amplitude
c. Level of consciousness
d. Mobility and gait stability
ANS: C
A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light- headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the clients level of consciousness is the priority
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the
presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the
nurse take next?
a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.
ANS: B
In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest
wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without
subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular
depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of
consciousness. The other interventions would not determine if the client is tolerating the loss of capture.
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should
the nurse perform prior to defibrillating this client?
a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.
ANS: D
To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures
their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is
available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is
defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients
understanding. Which statement by the client indicates a correct understanding of the teaching?
a. I should wear a snug-fitting shirt over the ICD. b. I will avoid sources of strong electromagnetic fields. c. I should participate in a strenuous exercise program. d. Now I can discontinue my antidysrhythmic medication.
ANS: B
The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients
should avoid tight clothing, which could cause irritation over the ICD generator. The client should be
encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed
the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed
medications.
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily
living. What interventions should the nurse implement to address this clients concerns?
a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client
ANS: C
Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing
activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease
fatigue. The other interventions will not assist the client with self-care activities.
. A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should
the nurse take prior to the initiation of cardioversion?
a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.
ANS: B
For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other
interventions are not appropriate for a cardioversion. The client should be placed in a supine position.
A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care
services. Which priority information should be communicated to the home health nurse upon discharge?
a. Medication reconciliation
b. Immunization history
c. Religious beliefs
d. Nutrition preferences
ANS: A
The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a
plan of care for the client.
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave
ANS: A
Chest pain, possibly angina, indicates that tachycardia may be increasing the clients myocardial workload and
oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial
hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions
and therefore do not require immediate intervention. The P wave touching the T wave indicates significant
tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important
assessment but is not as critical as chest pain, which indicates cardiac cell death.
A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by
palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this
clients teaching?
a. Minimize or abstain from caffeine. b. Lie on your side until the attack subsides. c. Use your oxygen when you experience PACs. d. Take amiodarone (Cordarone) daily to prevent PACs.
ANS: A
PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse
should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not
prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control
symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.
The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client
asks, Why do you want to know if I use cocaine? How should the nurse respond?
a. Substance abuse puts clients at risk for many health issues. b. The hospital requires that I ask you about cocaine use. c. Clients who use cocaine are at risk for fatal dysrhythmias. d. We can provide services for cessation of substance abuse.
ANS: C
Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other
responses do not adequately address the clients question.
A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?
a. Clean the skin and clip hairs if needed. b. Add gel to the electrodes prior to applying them. c. Place the electrodes on the posterior chest. d. Turn off oxygen prior to monitoring the client.
ANS: A
To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed
on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring
A nurse assesses a clients electrocardiogram (ECG) and observes the reading shown below:
How should the nurse document this clients ECG strip?
a. Ventricular tachycardia
b. Ventricular fibrillation
c. Sinus rhythm with premature atrial contractions (PACs)
d. Sinus rhythm with premature ventricular contractions (PVCs)
ANS: D
Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that
sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not
have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of
the atria before the sinus node initiates atrial depolarization.
A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below:
Which action should the nurse take first?
a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).
ANS: A
Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of
140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if
the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is
pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not
the first action.
A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The
clients blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse
assesses the clients rhythm on the cardiac monitor and observes the reading shown below:
Which action should the nurse take first?
a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.
ANS: C
This client is stable and therefore does not require any intervention except to determine the cause of the
bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the clients current
medications first.
The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has
no pulse. The cardiac monitor shows the rhythm below:
After calling for assistance and a defibrillator, which action should the nurse take next?
a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the clients family about code status.
ANS: B
The clients rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate
defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A
pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other
members of the team can insert one after defibrillation. The clients code status should already be known by the
nurse prior to this event.
A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.)
a. Decrease in cardiac output
b. Increase in cardiac output
c. Decrease in blood pressure
d. Increase in blood pressure
e. Decrease in urine output
f. Increase in urine output
ANS: A, D, E
Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However,
in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine
output will fall.
A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in
this clients teaching? (Select all that apply.)
a. Until your incision is healed, do not submerge your pacemaker. Only take showers. b. Report any pulse rates lower than your pacemaker settings. c. If you feel weak, apply pressure over your generator. d. Have your pacemaker turned off before having magnetic resonance imaging (MRI). e. Do not lift your left arm above the level of your shoulder for 8 weeks.
ANS: A, B, E
The client should not submerge in water until the site has healed; after the incision is healed, the client may
take showers or baths without concern for the pacemaker. The client should be instructed to report changes in
heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client
should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The
client should never apply pressure over the generator and should avoid tight clothing. The client should never
have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to
inform all health care providers that he or she has a pacemaker.
A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this
clients teaching? (Select all that apply.)
a. Smoking cessation
b. Stress reduction and management
c. Avoiding vagal stimulation
d. Adverse effects of medications
e. Foods high in potassium
ANS: A, B, D
A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take
medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at
risk for vasovagal attacks or potassium imbalances.
A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which
action should the nurse take when providing education about newly prescribed medications to this client?
a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the clients right side and speak into the right ear. d. Allow the client to use a white board to ask questions.
ANS: C
The temporal lobe contains the auditory center for sound interpretation. The clients hearing will be impaired in
the left ear. The nurse should sit on the clients right side and speak into the right ear. The other interventions do
not address the clients left temporal lobe damage.
A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which
intervention should the nurse include in this clients plan of care?
a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the clients legs. d. Assess the clients feet for wounds each shift.
ANS: B
Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing
the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The
other interventions do not address the clients problem.
A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse
include in this clients teaching?
a. Place soft rugs in your bathroom to decrease pain in your feet. b. Bathe in warm water to increase your circulation. c. Look at the placement of your feet when walking. d. Walk barefoot to decrease pressure ulcers from your shoes.
ANS: C
Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when
walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when
walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for
thermal injury. The client should wear sturdy shoes for ambulation.
A nurse assesses a clients recent memory. Which client statement confirms that the clients remote memory
is intact?
a. A young girl wrapped in a shroud fell asleep on a bed of clouds.
b. I was born on April 3, 1967, in Johnstown Community Hospital. c. Apple, chair, and pencil are the words you just stated. d. I ate oatmeal with wheat toast and orange juice for breakfast.
ANS: D
Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the
clients recent memory. The clients ability to make up a rhyme tests not memory, but rather a higher level of
cognition. Asking clients about certain facts from the past that can be verified assesses remote or long-term
memory. Asking the client to repeat words assesses the clients immediate memory.
A nurse assesses a client who demonstrates a positive Rombergs sign with eyes closed but not with eyes
open. Which condition does the nurse associate with this finding?
a. Difficulty with proprioception
b. Peripheral motor disorder
c. Impaired cerebellar function
d. Positive pronator drift
ANS: A
The client who sways with eyes closed (positive Rombergs sign) but not with eyes open most likely has a
disorder of proprioception and uses vision to compensate for it. The other options do not describe a positive
Rombergs sign.
A nurse asks a client to take deep breaths during an electroencephalography. The client asks, Why are you
asking me to do this? How should the nurse respond?
a. Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain. b. Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform. c. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity. d. Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures.
ANS: C
Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure
activity. The client is asked to breathe deeply 20 to 30 times for 3 minutes. The other responses are not
accurate.
A nurse assesses a client recovering from a cerebral angiography via the clients right femoral artery. Which
assessment should the nurse complete?
a. Palpate bilateral lower extremity pulses. b. Obtain orthostatic blood pressure readings. c. Perform a funduscopic examination. d. Assess the gag reflex prior to eating.
ANS: A
Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The
extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic blood pressure readings cannot be performed. The
funduscopic examination would not be affected by cerebral angiography. The client is given analgesics but not
conscious sedation; therefore, the clients gag reflex would not be compromised.
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test?
a. Have you had a recent blood transfusion?
b. Do you have allergies to iodine or shellfish?
c. Are you taking any cardiac medications?
d. Do you currently use oral contraceptives?
ANS: B
Allergies to iodine and/or shellfish need to be explored because the client may have a similar reaction to the
dye used in the procedure. In some cases, the client may need to be medicated with antihistamines or steroids
before the test is given. A recent blood transfusion or current use of cardiac medications or oral contraceptives
would not affect the angiography.
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed
tomography scan of the head with contrast medium. Which priority intervention should the nurse implement?
a. Educate the client about strict bedrest after the procedure. b. Place an indwelling urinary catheter to closely monitor output. c. Obtain a prescription for intravenous fluids. d. Contact the provider to cancel the procedure
ANS: C
If a contrast medium is used, intravenous fluid may be given to promote excretion of the contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid replacement. The client will not
require bedrest. Although urinary output should be monitored closely, there is no need for an indwelling
urinary catheter. There is no need to cancel the procedure as long as actions are taken to protect the kidneys.
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging
(MRI). Which condition should alert the nurse to contact the provider and cancel the procedure?
a. Creatine phosphokinase (CPK) of 100 IU/L
b. Atrioventricular graft
c. Blood urea nitrogen (BUN) of 50 mg/dL
d. Internal insulin pump
ANS: D
Metal devices such as internal pumps, pacemakers, and prostheses interfere with the accuracy of the image and
can become displaced by the magnetic force generated by an MRI procedure. An atrioventricular graft does not
contain any metal. CPK and BUN levels have no impact on an MRI procedure.
A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which
statement should the nurse include in this clients teaching?
a. Avoid caffeine-containing substances for 12 hours before the test. b. Drink at least 3 liters of fluid during the first 24 hours after the test. c. Do not take your cardiac medication the morning of the test. d. Remove your dentures and any metal before the test begins
ANS: A
Caffeine-containing liquids and foods are central nervous system stimulants and may alter the test results. No
contrast is used; therefore, the client does not need to increase fluid intake. The client should take cardiac
medications as prescribed. Metal does not have to be removed; this is done for magnetic resonance imaging.
A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, I am
worried I will not be able to care for my young children. How should the nurse respond?
a. Caring for your children is a priority. You may not want to ask for help, but you have to. b. Our community has resources that may help you with some household tasks so you have energy to care for
your children. c. You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?
d. Give me more information about what worries you, so we can see if we can do something to make
adjustments
ANS: D
Investigate specific concerns about situational or role changes before providing additional information. The
nurse should not tell the client what is or is not a priority for him or her. Although community resources may
be available, they may not be appropriate for the client. Consulting a psychologist would not be appropriate
without obtaining further information from the client related to current concerns.
A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this clients plan of care?
a. Provide a call button that requires only minimal pressure to activate. b. Write the date on the clients white board to promote orientation. c. Ensure that the path to the bathroom is free from equipment. d. Encourage the client to season food to stimulate nutritional intake
ANS: C
Dementia and confusion are not common phenomena in older adults. However, physical impairment related to
illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility
(and ensure safety). Providing a call button, providing the date, and seasoning food do not address the clients
impaired sensory perception.
After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the
clients understanding. Which client statement indicates a correct understanding of the teaching?
a. I must increase my fluids because of the dye used for the MRI. b. My urine will be radioactive so I should not share a bathroom. c. I can return to my usual activities immediately after the MRI. d. My gag reflex will be tested before I can eat or drink anything
ANS: C
No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is
complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not
needed and the clients urine would not be radioactive. The procedure does not impact the clients gag reflex.
A nurse performs an assessment of pain discrimination on an older adult client. The client correctly
identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should
the nurse take next?
a. Touch the pin on the same area of the left hand. b. Contact the provider with the assessment results. c. Ask the client about current medications. d. Continue the assessment on the clients feet
ANS: A
If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse should
continue the assessment on the left hand. This is a normal finding and does not need to be reported to the
provider, but instead documented in the clients chart. Medications do not need to be assessed in response to
this finding. The nurse should assess the left hand prior to assessing the feet.
A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include
in this clients discharge teaching?
a. Connect a light to flash when your door bell rings. b. Label your faucet knobs with hot and cold signs. c. Ask a friend to drive you to your follow-up appointments. d. Use a natural gas detector with an audible alar
ANS: C
Cerebellar function enables the client to predict distance or gauge the speed with which one is approaching an
object, control voluntary movement, maintain equilibrium, and shift from one skilled movement to another in
an orderly sequence. A client who has cerebellar function impairment should not be driving. The client would
not have difficulty hearing, distinguishing between hot and cold, or smelling.
A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement should the nurse
include when delegating care for a client with cranial nerve II impairment?
a. Tell the client where food items are on the breakfast tray. b. Place the client in a high-Fowlers position for all meals. c. Make sure the clients food is visually appetizing. d. Assist the client by placing the fork in the left hand
ANS: A
Cranial nerve II, the optic nerve, provides central and peripheral vision. A client who has cranial nerve II
impairment will not be able to see, so the UAP should tell the client where different food items are on the meal
tray. The other options are not appropriate for a client with cranial nerve II impairment.
A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider? a. Shingles on the clients back b. Client is claustrophobic c. Absence of intravenous access d. Paroxysmal nocturnal dyspnea
ANS: A
An LP should not be performed if the client has a skin infection at or near the puncture site because of the risk
of infection. A nurse would want to notify the health care provider if shingles were identified on the clients
back. If a client has shortness of breath when lying flat, the LP can be adapted to meet the clients needs. Claustrophobia, absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP
can be performed.
A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication of this
procedure should alert the nurse to urgently contact the health care provider?
a. Weak pedal pulses
b. Nausea and vomiting
c. Increased thirst
d. Hives on the chest
ANS: B
The nurse should immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased
intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP.
A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT)
with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care
with this client?
a. You may return to your previous activity level immediately. b. You are radioactive and must use a private bathroom. c. Frequent assessments of the injection site will be completed. d. We will be monitoring your renal functions closely
ANS: A
The client may return to his or her previous activity level immediately. Radioisotopes will be eliminated in the
urine after SPECT, but no monitoring or special precautions are required. The injection site will not need to be
assessed after the procedure is complete.
A nurse assesses a client and notes the clients position as indicated in the illustration below:
How should the nurse document this finding?
a. Decorticate posturing
b. Decerebrate posturing
c. Atypical hyperreflexia
d. Spinal cord degeneration
ANS: A
The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the clients condition has deteriorated. The physician, the charge
nurse, and other health care team members should be notified immediately of this change in status. Decerebrate
posturing consists of external rotation and extension of the extremities. Hyperreflexes present as increased
reflex responses. Spinal cord degeneration presents frequently with pain and discomfort.
A nurse assesses the left plantar reflexes of an adult client and notes the response shown in the photograph
below:
Which action should the nurse take next?
a. Contact the provider with this abnormal finding. b. Assess bilateral legs for temperature and edema. c. Ask the client about pain in the lower leg and calf. d. Document the finding and continue the assessment.
ANS: A
This finding indicates Babinskis sign. In clients older than 2 years of age, Babinskis sign is considered
abnormal and indicates central nervous system disease. The nurse should notify the health care provider and
other members of the health care team because further investigation is warranted. This finding does not relate
to perfusion of the leg or to pain. This is an abnormal assessment finding and should be addressed
immediately.
nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How should the nurse document this clients
assessment using the Glasgow Coma Scale shown below?
a. 8
b. 10
c. 12
d. 14
ANS: C
The client opens his eyes to speech (Eye opening: To sound = 3), mumbles in response to questions (Verbal
response: Inappropriate words = 3), and follows simple commands (Motor response: Obeys commands = 6). Therefore, the clients Glasgow Coma Scale score is: 3 + 3 + 6 = 12.
A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Loss of smell b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex
ANS: B, D, E
Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the
medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes
impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not
associated with damage to the medulla.
An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball. For which clinical manifestations that are related to a temporal lobe injury should the nurse assess? (Select all that apply.) a. Memory loss b. Personality changes c. Difficulty with sound interpretation d. Speech difficulties e. Impaired taste
ANS: A, C, D
Wernickes area (language area) is located in the temporal lobe and enables the processing of words into
coherent thought as well as the understanding of written or spoken words. The temporal lobe also is
responsible for the auditory centers interpretation of sound and complicated memory patterns. Personality
changes are related to frontal lobe injury. Impaired taste is associated with injury to the parietal lobe.
After administering a medication that stimulates the sympathetic division of the autonomic nervous system,
the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply.)
a. Decreased respiratory rate
b. Increased heart rate
c. Decreased level of consciousness
d. Increased force of contraction
e. Decreased blood pressure
ANS: B, D
Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart
rate and the force of contraction. A medication that stimulates the sympathetic nervous system would also
increase the clients respiratory rate, blood pressure, and level of consciousness.
A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the
nurse to urgently communicate with the health care provider? (Select all that apply.)
a. Glasgow Coma Scale score of 8
b. Decerebrate posturing
c. Reactive pupils
d. Uninhibited speech
e. Diminished cognition
ANS: A, B, E
The nurse should urgently communicate changes in a clients neurologic status, including a decrease in the
Glasgow Coma Scale score, abnormal flexion or extension, changes in cognition or speech, and pinpointed, dilated, and nonreactive pupils.
A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based
contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)
a. Ensure that an informed consent is present. b. Ask the client about any allergies. c. Evaluate the clients renal function. d. Auscultate bilateral breath sounds. e. Assess hematocrit and hemoglobin levels
ANS: A, B, C
A client who is scheduled to receive iodine-based contrast should be asked about allergies, especially allergies
to iodine or shellfish. The clients kidney function should also be evaluated to determine if it is safe to
administer contrast during the procedure. Finally, the nurse should ensure that an informed consent is present
because all clients receiving iodine-based contrast must give consent. The CT will have no impact on the
clients breath sounds or hematocrit and hemoglobin levels. Findings from these assessments will not influence
the clients safety during the procedure.
A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in
the nervous system related to aging? (Select all that apply.)
a. Long-term memory loss
b. Slower processing time
c. Increased sensory perception
d. Decreased risk for infection
e. Change in sleep patterns
ANS: B, E
Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception
of pain, and altered balance and/or decreased coordination
A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which
statements should the nurse include when delegating this clients care? (Select all that apply.)
a. Plan to bathe the client in the evening when the client is most alert. b. Encourage the client to use a cane when ambulating. c. Assess the client for symptoms related to pain and discomfort. d. Remind the client to look at foot placement when walking. e. Schedule additional time for teaching about prescribed therapies
ANS: A, B, D
The nurse should tell the UAP to schedule activities when the client is normally awake, encourage the client to
use a cane when ambulating, and remind the client to look where feet are placed when walking. The nurse
should assess the client for symptoms of pain and should provide sufficient time for older adults to process
information, including new teaching. These are not items the nurse can delegate.
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which
statement should the nurse include in this clients teaching?
a. Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache. b. Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine
headaches. c. This drug will relieve the pain during the aura phase soon after a headache has started. d. This medication will have no effect on your heart rate or blood pressure because you are taking it for
migraines.
ANS: B
Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine
headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.
A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse
identify as an early sign of a migraine with aura?
a. Vertigo
b. Lethargy
c. Visual disturbances
d. Numbness of the tongue
ANS: C
Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with a
A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex)
for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health
care provider?
a. Bronchial asthma
b. Prinzmetals angina
c. Diabetes mellitus
d. Chronic kidney disease
ANS: B
Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by
binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined
to the cranium and can cause coronary vasospasm in clients with Prinzmetals angina. The other conditions
would not affect the clients treatment.
A nurse assess a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure
ANS: B
Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking
of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of
muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of
extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is
unaware of his or her environment.
A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action
should the nurse take?
a. Start fluids via a large-bore catheter. b. Turn the clients head to the side. c. Administer IV push diazepam. d. Prepare to intubate the client.
ANS: B
The nurse should turn the clients head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status
epilepticus), the client must be intubated and should be administered oxygen, 0.9% sodium chloride, and IV
push lorazepam or diazepam.
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)
ANS: B
Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the
administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme
inhibitor, are not administered for seizure activity. These medications are typically administered for
hypertension and heart failure.
After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin
(Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct
understanding of the teaching?
a. To prevent complications, I will drink at least 2 liters of water daily.
b. This medication will stop me from getting an aura before a seizure. c. I will not drive a motor vehicle while taking this medication. d. Even when my seizures stop, I will continue to take this drug.
ANS: D
Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does
not need to drink more water and can drive while taking this medication. The medication will not stop an aura
before a seizure.
After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which
statement by the client indicates a need for additional teaching?
a. I will wear my medical alert bracelet at all times. b. While taking my epilepsy medications, I will not drink any alcoholic beverages. c. I will tell my doctor about my prescription and over-the-counter medications. d. If I am nauseated, I will not take my epilepsy medication
ANS: D
The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing
the medication can predispose the client to seizure activity and status epilepticus. The client should not drink
alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the
doctor aware of all medications to prevent complications of polypharmacy.
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which
question should the nurse ask?
a. Do you live in a crowded residence?
b. When was your last tetanus vaccination?
c. Have you had any viral infections recently?
d. Have you traveled out of the country in the last month?
ANS: A
Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high- density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would
not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection
would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled
out of the country does not provide enough information. The nurse should ask about travel to specific countries
in which the disease is common, for example, sub-Saharan Africa.
After teaching the wife of a client who has Parkinson disease, the nurse assesses the wifes understanding. Which statement by the clients wife indicates she correctly understands changes associated with this disease?
a. His masklike face makes it difficult to communicate, so I will use a white board. b. He should not socialize outside of the house due to uncontrollable drooling. c. This disease is associated with anxiety causing increased perspiration. d. He may have trouble chewing, so I will offer bite-sized portions.
ANS: D
Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for
meeting the clients nutritional needs. A masklike face and drooling are common in clients with Parkinson
disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the clients masklike face can be misinterpreted and additional time may be
needed for the client to communicate with her or others. Excessive perspiration is also common in clients with
Parkinson disease and is associated with the autonomic nervous systems response.
A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this
clients plan of care?
a. Ambulate the client in the hallway twice a day. b. Ensure a fluid intake of at least 3 liters per day. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater
ANS: D
Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of
the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous
thrombosis. Increased fluid intake flushes out toxins from the clients blood. Pursed-lip breathing increases
exhalation of carbon dioxide.
A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, Will the
medication my mother is taking improve her dementia? How should the nurse respond?
a. It will allow your mother to live independently for several more years. b. It is used to halt the advancement of Alzheimers disease but will not cure it. c. It will not improve her dementia but can help control emotional responses. d. It is used to improve short-term memory but will not improve problem solving.
ANS: C
Drug therapy is not effective for treating dementia or halting the advancement of Alzheimers disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations. Medication
therapy may not allow the client to safely live independently.
A nurse assesses a client with Alzheimers disease who is recently admitted to the hospital. Which
psychosocial assessment should the nurse complete?
a. Assess religious and spiritual needs while in the hospital. b. Identify the clients ability to perform self-care activities. c. Evaluate the clients reaction to a change of environment. d. Ask the client about relationships with family members.
ANS: C
As Alzheimers disease progresses, the client experiences changes in emotional and behavioral affect. The
nurse should be alert to the clients reaction to a change in environment, such as being hospitalized, because client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be
completed but are not as important as assessing the clients reaction to environmental change.
A nurse witnesses a client with late-stage Alzheimers disease eat breakfast. Afterward the client states, I am
hungry and want breakfast. How should the nurse respond?
a. I see you are still hungry. I will get you some toast. b. You ate your breakfast 30 minutes ago. c. It appears you are confused this morning. d. Your family will be here soon. Lets get you dressed.
ANS: A
Use of validation therapy with clients who have Alzheimers disease involves acknowledgment of the clients
feelings and concerns. This technique has proved more effective in later stages of the disease, when using
reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate
the client. The other statements do not validate the clients concerns.
A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests
should the nurse monitor for potential adverse effects of this medication?
a. Serum electrolyte levels
b. Kidney function tests
c. Complete blood cell count
d. Antinuclear antibodies
ANS: B
Adverse effects of levetiracetam include coordination problems and renal toxicity. The other laboratory tests
are not affected by levetiracetam.
A nurse cares for a client with advanced Alzheimers disease. The clients caregiver states, She is always
wandering off. What can I do to manage this restless behavior? How should the nurse respond?
a. This is a sign of fatigue. The client would benefit from a daily nap. b. Engage the client in scheduled activities throughout the day. c. It sounds like this is difficult for you. I will consult the social worker. d. The provider can prescribe a mild sedative for
ANS: B
Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in
structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be
as effective in the management of restless behavior. Consulting the social worker does not address the
caregivers concern.
. A nurse prepares to discharge a client with Alzheimers disease. Which statement should the nurse include
in the discharge teaching for this clients caregiver?
a. Allow the client to rest most of the day. b. Place a padded throw rug at the bedside. c. Install deadbolt locks on all outside doors. d. Provide a high-calorie and high-protein diet.
ANS: C
Clients with Alzheimers disease have a tendency to wander, especially at night. If possible, alarms should be
installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors
should have deadbolt locks installed to prevent the client from going outdoors unsupervised. The client should
be allowed to exercise within his or her limits. Throw rugs are a slip and fall hazard and should be removed. The client should eat a well-balanced diet. There is no need for a high-calorie or high-protein diet.
A nurse assesses a client with Huntington disease. Which motor changes should the nurse monitor for in this client? a. Shuffling gait b. Jerky hand movements c. Continuous chewing motions d. Tremors of the hands
ANS: B
An imbalance between excitatory and inhibitory neurotransmitters leads to uninhibited motor movements, such
as brisk, jerky, purposeless movements of the hands, face, tongue, and legs. Shuffling gait, continuous chewing
motions, and tremors are associated with Parkinson disease.
A nurse cares for a client who has been diagnosed with the Huntington gene but has no symptoms. The
client asks for options related to family planning. What is the nurses best response?
a. Most clients with the Huntington gene do not pass on Huntington disease to their children. b. I understand that they can diagnose this disease in embryos. Therefore, you could select a healthy embryo
from your fertilized eggs for implantation to avoid passing on Huntington disease. c. The need for family planning is limited because one of the hallmarks of Huntington disease is infertility. d. Tell me more specifically what information you need about family planning so that I can direct you to the
right information or health care provider.
ANS: D
The presence of the Huntington gene means that the trait will be passed on to all offspring of the affected
person. Understanding options for contraception and conception (e.g., surrogacy options) and implications for
children may require the expertise of a genetic counselor or a reproductive specialist. The other statements are
not accurate.
A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary
therapy should the nurse include in this clients teaching?
a. Place a warm compress on your forehead at the onset of the headache.
b. Wear dark sunglasses when you are in brightly lit spaces. c. Lie down in a darkened room when you experience a headache. d. Set your alarm to ensure you do not sleep longer than 6 hours at one time.
ANS: C
At the onset of a migraine attack, the client may be able to alleviate pain by lying down and darkening the
room. He or she may want both eyes covered and a cool cloth on the forehead. If the client falls asleep, he or
she should remain undisturbed until awakening. The other options are not recognized therapies for migraines.
. A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care?
a. Allow the client to be as independent as possible with activities. b. Assist the client with frequent and meticulous oral care. c. Assess the clients ability to eat and swallow before each meal. d. Schedule appointments early in the morning to ensure rest in the afternoon.
ANS: A
Clients with Parkinson disease do not move as quickly and can have functional problems. The client should be
encouraged to be as independent as possible and provided time to perform activities without rushing. Although
oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a
priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The
nurse should assess the clients ability to eat and swallow; this should not be delegated. Appointments and
activities should not be scheduled early in the morning because this may cause the client to be rushed and
discourage the client from wanting to participate in activities of daily living.
A nurse delegates care for a client with early-stage Alzheimers disease to an unlicensed assistive personnel
(UAP). Which statement should the nurse include when delegating this clients care?
a. If she is confused, play along and pretend that everything is okay. b. Remove the clock from her room so that she doesnt get confused. c. Reorient the client to the day, time, and environment with each contact. d. Use validation therapy to recognize and acknowledge the clients concerns.
ANS: C
Clients who have early-stage Alzheimers disease should be reoriented frequently to person, place, and time. The UAP should reorient the client and not encourage the clients delusions. The room should have a clock and
white board with the current date written on it. Validation therapy is used with late-stage Alzheimers disease.
A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the
nurse include in this clients plan of care? (Select all that apply.)
a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids.
d. Keep bed rails up at all times. e. Maintain the client on strict bedrest.
f. Ensure that the client has IV access.
ANS: A, D, F
Oxygen and suctioning equipment with an airway must be readily available. The bed rails should be up at all
times while the client is in the bed to prevent injury from a fall if the client has a seizure. If the client does not
have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized
tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the
seizure. Padded tongue blades may pose a danger to the client during a seizure and should not be used. Dietary
restrictions and strict bedrest are not interventions associated with epilepsy. The client should be encouraged to
eat a well-balanced diet and ambulate while in the hospital.
A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should
the nurse include in this clients plan of care? (Select all that apply.)
a. Increase your intake of caffeinated beverages. b. Incorporate physical exercise into your daily routine. c. Avoid all alcoholic beverages. d. Participate in a smoking cessation program. e. Increase your intake of fruits and vegetables.
ANS: B, D, E
Triggers for headaches include caffeine, smoking, and ingestion of pickled foods, so these factors should be
avoided. Clients are taught to eat a balanced diet and to get adequate exercise and rest. Alcohol does not trigger
chronic headaches but can enhance headaches during the headache period.
A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells
ANS: A, C, D
In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose levels are normal. Viral
meningitis does not cause cloudiness or increased turbidity of CSF. In bacterial meningitis, the presence of
bacteria and white blood cells causes the fluid to be cloudy
A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Ipsilateral tearing of the eye b. Miosis c. Abrupt loss of consciousness d. Neck and shoulder tenderness e. Nasal congestion f. Exophthalmos
ANS: A, B, E
Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and
exophthalmos are not associated with cluster headaches.
A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Intermittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at clothing f. Patting of the hand on the leg
ANS: B, E, F
Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at
clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the
extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.
A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal
protective equipment should the nurse wear? (Select all that apply.)
a. Particulate respirator
b. Isolation gown
c. Shoe covers
d. Surgical mask
e. Gloves
ANS: D, E
Meningeal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers
should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions,
including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet
Precautions.
A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for
secondary seizures? (Select all that apply.)
a. A 26-year-old woman with a left temporal brain tumor
b. A 38-year-old male client in an alcohol withdrawal program
c. A 42-year-old football player with a traumatic brain injury
d. A 66-year-old female client with multiple sclerosis
e. A 72-year-old man with chronic obstructive pulmonary disease
ANS: A, B, C
Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who
are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple
sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.
A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures
ANS: C, D
Complications of surgery to implant a vagal nerve stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the
vagus nerve to control simple or complex partial seizures. Bleeding is not a common complication of this
procedure, and infection would not occur during the recovery period.
A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify
potential complications of this disorder? (Select all that apply.)
a. Sodium level
b. Liver enzymes
c. Clotting factors
d. Cardiac enzymes
e. Creatinine level
ANS: A, C
Inflammation associated with meningitis can stimulate the hypothalamus and result in excessive production of
antidiuretic hormone. The nurse should monitor sodium levels for early identification of syndrome of
inappropriate antidiuretic hormone. A systemic inflammatory response (SIR) can also occur with meningitis. A
SIR can result in a coagulopathy that leads to disseminated intravascular coagulation. The nurse should
monitor clotting factors to identify this complication. The other laboratory values are not specific to
complications of meningitis.
A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of
increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.)
a. Photophobia
b. Dilated pupils
c. Headache
d. Widened pulse pressure
e. Bradycardia
ANS: B, D, E
Increased ICP is a complication of encephalitis. The nurse should monitor for signs of increased ICP, including
dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are not related to increased ICP.
A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which
instruction should the nurse include in this education?
a. Participate in an exercise program to strengthen muscles. b. Purchase a mattress that allows you to adjust the firmness. c. Wear flat instead of high-heeled shoes to work each day. d. Keep your weight within 20% of your ideal body weight
ANS: A
Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not
prevent low back pain.
A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should
the nurse include in this clients plan of care?
a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers
ANS: C
Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will
not promote healing, and there is no need to avoid warm baths or showers.
A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first? a. Sleepy but arouses to voice b. Dry and cracked oral mucosa c. Pain present in lower back d. Bladder palpated above pubis
ANS: D
A distended bladder may indicate damage to the sacral spinal nerves. The other findings require the nurse to
provide care but are not the priority or a complication of the procedure.
A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain?
a. A 24-year-old female who is 25 weeks pregnant
b. A 36-year-old male who uses ergonomic techniques
c. A 45-year-old male with osteoarthritis
d. A 53-year-old female who uses a walker
ANS: C
Osteoarthritis causes changes to support structures, increasing the clients risk for low back pain. The other clients are not at high risk
A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in
this clients postoperative instructions?
a. Only lift items that are 10 pounds or less. b. Wear your brace whenever you are out of bed. c. You must remain in bed for 3 weeks after surgery. d. You are prescribed medications to prevent rejection
ANS: B
Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process
(usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not
need to remain in bed. Medications for rejection prevention are not necessary for this procedure.
A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which
complication should alert the nurse to urgently communicate with the health care provider?
a. Auscultated stridor
b. Weak pedal pulses
c. Difficulty swallowing
d. Inability to shrug shoulders
ANS: A
Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The
client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an
inability to shrug the shoulders are not complications of this surgery.
nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?
a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.
ANS: C
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight
clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic
injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be
appropriate.
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via
emergency medical services. Which action should the nurse take first?
a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.
ANS: D
The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require
intubation. The other assessments should be performed after airway and breathing are assessed.
An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which
prescribed medication should the nurse prepare to administer?
a. Intrathecal baclofen (Lioresal)
b. Methylprednisolone (Medrol)
c. Atropine sulfate
d. Epinephrine (Adrenalin)
ANS: B
Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy
usually show improvement in motor and sensory function. The other medications are inappropriate for this
client.
A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which
statement should the nurse include in this clients teaching?
a. Stroke the inner aspect of your thigh to initiate voiding. b. Use a clean technique for intermittent catheterization. c. Implement digital anal stimulation when your bladder is full. d. Tighten your abdominal muscles to stimulate urine flow.
ANS: D
In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or
tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the
thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and
digital anal stimulation do not initiate voiding or bladder control.
A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, I do not understand the need for rehabilitation; the paralysis will not go away and it will not
get better. How should the nurse respond?
a. If you dont want to participate in the rehabilitation program, Ill let the provider know. b. Rehabilitation programs have helped many clients with your injury. You should give it a chance. c. The rehabilitation program will teach you how to maintain the functional ability you have and prevent
further disability.
d. When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.
ANS: C
Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of
functional ability, and restoration of function. The other responses do not meet this clients needs.
After teaching a client with a spinal cord injury, the nurse assesses the clients understanding. Which client
statement indicates a correct understanding of how to prevent respiratory problems at home?
a. Ill use my incentive spirometer every 2 hours while Im awake. b. Ill drink thinned fluids to prevent choking. c. Ill take cough medicine to prevent excessive coughing. d. Ill position myself on my right side so I dont aspirate.
ANS: A
Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for
developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client
expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually
thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should
be placed in high-Fowlers position to prevent aspiration.
A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance
ANS: C
Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive
reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.
A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which
prescribed medication should the nurse prepare to administer?
a. Baclofen (Lioresal)
b. Interferon beta-1b (Betaseron)
c. Dantrolene sodium (Dantrium)
d. Methylprednisolone (Medrol)
ANS: D
Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used
to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific
symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen
muscle spasticity associated with MS.
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For
which adverse effect should the nurse monitor?
a. Peripheral edema
b. Black tarry stools
c. Bradycardia
d. Nausea and vomiting
ANS: C
Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours
after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects
of fingolimod.
A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and
methylprednisolone (Medrol). Which statement should the nurse include in this clients discharge teaching?
a. Take warm baths to promote muscle relaxation. b. Avoid crowds and people with colds. c. Relying on a walker will weaken your gait. d. Take prescribed medications when symptoms occur.
ANS: B
The client should be taught to avoid people with any type of upper respiratory illness because these
medications are immunosuppressive. Warm baths will exacerbate the clients symptoms. Assistive devices may
be required for safe ambulation. Medication should be taken at all times and should not be stopped.
A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as
a late manifestation of amyotrophic lateral sclerosis (ALS)?
a. Dysarthria
b. Dysphagia
c. Muscle weakness
d. Impairment of respiratory muscles
ANS: D
In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory
muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are
early clinical manifestations of ALS.
A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the
nurse to ensure that an informed consent has been obtained before the test or procedure?
a. Sensation measurement via the pinprick method b. Computed tomography of the cranial vault
c. Lumbar puncture for cerebrospinal fluid sampling
d. Venipuncture for autoantibody analysis
ANS: C
A lumbar puncture is an invasive procedure with many potentially serious complications. The other
assessments or tests are considered noninvasive and do not require an informed consent.
A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse
implement prior to the test?
a. Implement nothing by mouth (NPO) status for 8 hours. b. Withhold all daily medications until after the examination. c. Administer morphine sulfate to prevent claustrophobia during the test. d. Place the client in a gown that has cloth ties instead of metal snaps.
ANS: D
Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not
administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The
client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.
A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the
nurse consult to assist the client with activities of daily living?
a. Social worker
b. Physical therapist
c. Occupational therapist
d. Case manager
ANS: C
The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with
the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated
issues
A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, I do not want to be
placed on a mechanical ventilator. How should the nurse respond?
a. You should discuss this with your family and health care provider. b. Why are you afraid of being placed on a breathing machine?
c. Using the incentive spirometer each hour will delay the need for a ventilator. d. What would you like to be done if you begin to have difficulty breathing?
ANS: D
ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness, muscle
wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must
indicate in the advance directive what is to be done when breathing is no longer possible without intervention. The other statements do not address the clients needs.
A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask?
a. Are you taking a nonsteroidal anti-inflammatory drug?
b. Do you have a mental health disorder?
c. Are you able to swallow medications?
d. Do you smoke cigarettes or any illegal drugs?
ANS: B
Clients who have a mental health or behavioral health problem should not take ziconotide. The other questions
do not identify a contraindication for this medication.
A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the clients coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies
ANS: A, C, D, F
Information about the clients preinjury psychosocial status, usual methods of coping with illness, difficult
situations, and disappointments should be obtained. Determine the clients level of independence or dependence
and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients
who are emotionally secure and have a positive self-image, a supportive family, and financial and job security
often adapt to their injury. Information about the clients spiritual and religious beliefs or cultural background
also assists the nurse in developing the plan of care. The other options do not supply as much information
about coping.
After teaching a client with a spinal cord tumor, the nurse assesses the clients understanding. Which
statements by the client indicate a correct understanding of the teaching? (Select all that apply.)
a. Even though turning hurts, I will remind you to turn me every 2 hours. b. Radiation therapy can shrink the tumor but also can cause more problems. c. Surgery will be scheduled to remove the tumor and reverse my symptoms. d. I put my affairs in order because this type of cancer is almost always fatal. e. My family is moving my bedroom downstairs for when I am discharged home.
ANS: A, B, E
Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some
motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal. Radiation therapy is often used to shrink spinal tumors but can cause progressive spinal cord degeneration and neurologic deficits. The client should be turned every 2 hours to prevent skin breakdown and arrangements
should be made at home so that the client can complete activities of daily living without needing to go up and
down stairs.
