Midterm

Question 1

Initially after a brain attack (stroke, cerebrovascular accident), a client’s pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client’s systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care?

Answer 1

ICP
Rationale: Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure.

Question 2

A patient undergoing radiation therapy for breast cancer reports feeling fatigue during normal daily activities. The nurse indicates that the patient may be at risk for anemia due to which physiological effect of cancer treatment.

Answer 2

Decreased number of red blood cell precursor

Rationale: Radiation can decrease the production of red​​ blood cell precursors, leading to a decrease in the production of red blood cells, resulting in anemia

Question 3

A medication that helps chemotherapeutic agents cross the blood brain barrier is ______________.

Answer 3

Mannitol
Rationale: Hyperosmolar. Mannitol can be administered to alter the blood brain barrier and allow the brain to uptake the medication.

Question 4

The patient and family are referred to the nurse for education about amyotrophic lateral sclerosis, ALS. What information does the nurse include in the educational session? Select all that apply.

Answer 4

It is a progressive disease involving the motor system.
The cause of ALS is unknown.
There is no known cure for ALS.

Question 5

The nurse is caring for a client who has a vertebral fracture. Which intervention does the nurse implement to prevent deterioration of the client’s neurologic status?

Answer 5

Immobilize the affected portion of the spinal column.

Rationale: The nurse keeps the client in the optimal body alignment at all times, avoiding flexion and extension at the site of vertebral injury to prevent further cord injury or irritability from bone fragments

Question 6

The nurse is taking the initial history and vitals on a patient with fatigue. The nurse notes a regular apical pulse of 130 beats/min. Which contributing factors does the nurse assess for? Select all that apply.

Answer 6

Anxiety for stress
Fever
Hypovolemia
Anemia of Hypoxemia

Question 7

The nurse is administering IV dexamethasone to a patient with a frontal lobe tumor who reports left upper quadrant pain, nausea, and vomiting. Upon assessment, the nurse notes, coffee ground, emesis, and tenderness on palpation. Which provider order would the nurse anticipate?

Answer 7

Insert NG tube

Rationale: The nurse would expect to insert a NG tube to decompress the stomach in a patient with active GI bleeding to prevent aspiration.

Question 8

A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be. 184 / 95 mm Hg. Which is the nurse’s first action?

Answer 8

palpate the area over the bladder for distension

Rationale: 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.

Question 9

Emergency medical services arrived to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time?

Answer 9

Respiratory pattern and airway

Question 10

What response would be the best response to a client with a new spinal cord injury (SCI) who asks if his current paralysis will be permanent?

Answer 10

There is often a period of spinal shock when it is difficult to determine if the paralysis will be permanent, and when it resolves there can be some regaining of abilities

Question 11

The nurse is planning discharge teaching for a client who had peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan?

Answer 11

Use a thermometer to check the temp of bathwater

Rationale: The client with neuropathy has loss of sensation in the lower extremities, which can predispose the client to thermal injury. The client should be instructed to use a thermometer to check the temperature of the bath water to avoid a burn. Checking the water with the hands is not recommended because neuropathy may have a stocking and glove distribution that could also affect the hands. The client should be taught to wear shoes at all times, to assess feet and legs daily, to keep skin moist and clean, and not to cut calluses or corns from the feet.

Question 12

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department. For treatment on the evening shift. The nurse should assign priority to which client?

Answer 12

Patient with chest pain

Question 13

The nurse is assessing a client schedule for a lumbar puncture, which clinical manifestation assessed by the nurse complicates the lumbar puncture procedure?

Answer 13

restlessness and agitation

Question 14

When Romberg’s test is used as a diagnostic tool, the nurse is:

Answer 14

Test performed to assess sense of balance and proprioception, it is used to investigate cause of loss of motor coordination. The nurse will ask the patient to stand with feet close to each other and eyes closed. If patient sways to one side positive Rombergs test

Question 15

The spinal cord injured patient starts to develop respiratory distress. What action should the nurse take to keep the airway open without compromising the patient’s spine further?

Answer 15

Perform the jaw-thrust technique.

Question 16

Damage to upper motor neuron will result in:

Answer 16

spasticity

Question 17

The nurse is caring for a patient with a relatively minor head injury after a bump on the head. The nurse has the greatest concern for which symptom?

Answer 17

Unequal pupils

Question 18

The neurologic assessment of a client who had a craniotomy includes the Glasgow Coma Scale. What does the nurse evaluate to assess the client’s score on the Glasgow Coma Scale? Select all that apply

Answer 18

• Degree of purposeful movement by the client
  -Appropriateness of clients verbal responses
• Stimulus necessary to cause the clients eyes to open

Question 19

A patient with non-Hodgkin’s lymphoma. Asked why staging is so important. Which is the accurate response to his question? Staging is completed to:

Answer 19

determine chemo protocol

Question 20

The nurse is teaching a client who has a spinal cord injury how to prevent respiratory problems at home. Which statement indicates that the client currently understands this teaching?

Answer 20

I will use my incentive spirometer every 2 hours while I’m awake

Question 21

A secondary brain tumor:

Answer 21

Started somewhere else in the body and spread to the brain

Question 22

Which are the two priority nursing diagnoses for the person undergoing chemotherapy for leukemia?

Answer 22

Risk for infection/ risk for injury

Question 23

The nurse is planning care for a client who has a spinal cord injury. The ______ therapist is a member of the interdisciplinary team that assists the patient with activities of daily living.

Answer 23

Occupational Therapy

Question 24

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action?

Answer 24

Encourage the client to discuss the use of an herbal substance with the health care provider

Question 25

Which symptoms indicate that a patient with spinal cord injury is experiencing autonomic dysreflexia? Select all that apply.

Answer 25

Headache
Bradycardia
Hypertension
Nasal stuffiness

Question 26

Which nursing action is appropriate for a client in sickle cell crisis?

Answer 26

Administer O2
Administer prescribed narcotics
Force fluids

Question 27

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 4.5. On the basis of these laboratory findings, the nurse anticipates which MD order?

Answer 27

Holding the next dose of Warfarin

Question 28

What should the nurse monitor as an adverse reaction when a client is receiving a platelet aggregation inhibitor as clopidigrel (Plavix)?

Answer 28

Epitaxis

Question 29

The patient is being evaluated for thrombolytic therapy. What are absolute contraindications for this procedure? Select all that apply.

Answer 29

Intracranial Hemorrhage
Suspected aortic aneurysm
Malignant intracranial neoplasm
Ischemic stroke within 3 months

Question 30

A bone marrow biopsy reveals which characteristic finding associated with Acute Myelogenous Leukemia (AML)?

Answer 30

Immature Myloblast

Question 31

Meet the client: Ryan Stapleton is a 20-year-old college student attending school in Colorado away from his home in Arizona. He is playing football with some of his friends in the park. He jumps in the air to catch the football and is tackled by another player. Ryan flips in the midair and feels something pop in his neck as he lands hard on the ground. He does not have any pain, but when he tries to get up, he cannot move his legs or arms. Ryan is alert and is talking to his friends.

What should Ryan’s friend do while waiting for the emergency personnel to arrive?

Answer 31

-Place blanket over Ryan and make sure no one moves him.
Any movement or improper handling could cause further damage and loss of neurological function.

-Ensure that the scene around Ryan is safe and that he is not in any immediate danger.
Ensuring that the scene is safe and protecting Ryan from any immediate danger is important.

Question 32

The nurses giving home care instructions to a patient who will be discharged with a Halo device. What should the nurse instruct the patient to avoid? Select all that apply.

Answer 32

-Driving
-Swimming or contact sports

Question 33

The purpose of carotid endarterectomy is to:

Answer 33

Removing plaque build-up within the carotid artery

Question 34

The client with new onset status epilepticus is prescribed phenytoin Dilantin. After teaching the client about the treatment regimen, the nurse assesses the client’s understanding. Which statement indicates that the client understands his teaching?

Answer 34

Even when my seizures stop I will take this drug

Question 35

Packed red blood cells have been prescribed to a female patient with a hemoglobin level of 7.6g/dL. (7 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the patient’s temperature before hanging the blood transfusion and records 100.8 F (38.1 C) orally. Which action should the nurse take?

Answer 35

Delay hanging the blood and notify the health care provider (HCP)

Rationale: If the client has a temperature higher than 100 F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse’s scope of practice to make. The nurse needs an HCP’s prescription to administer medications to the client.

Question 36

A 19-year-old is brought to the emergency department with sudden onset of high fever, nuchal rigidity and vomiting. These signs and symptoms are suggestive of ___________

Answer 36

Meningitis

Question 37

The nurse is assessing a client with trigeminal neuralgia. Which clinical manifestation does the nurse expect to observe?

Answer 37

Controllable facial twitching

Question 38

To interrupt seizure activity in a patient with status epilepticus, the patient must receive.

Answer 38

Ativan (lorazepam) and Valium (diazepam)

Question 39

Which statement regarding deep vein thrombosis DVT in the patient with a spinal cord injury is true?

Answer 39

nurse should assess any signs of internal bleeding and any history of recent surgery, HCP will order to administer Low molecular weight heparin

Question 40

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client’s laboratory report, should be reported before administering the dose of furosemide?

Answer 40

3.2 mEq/L

Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L. The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.

Question 41

The nurse would use which statement to describe to the patient with coronary artery disease (CAD) how fatty streaks are formed?

Answer 41

“Damaged arteries allow lipids to be deposited in the intima.”

Rationale: Damaged arteries allow lipids to be deposited in the inside of the artery to form fatty streaks, beginning the process of atherosclerosis.

Question 42

The nurse is caring for a patient who has been in a long-term care facility for several months following a spinal cord injury (SCI) the patient has had issues with urinary retention at subsequent overflow, incontinence and a bladder retraining program was recently initiated. Which are expected outcomes for the training program? Select all that apply.

Answer 42

• Demonstrates a predictable pattern of voiding
• is able to empty bladder completely
• does not experience any UTI

Question 43

The brief sensory experience that occurs prior to onset of seizure is called _________.

Answer 43

Prodromal

Question 44

The nurse is caring for a client admitted to the intensive care unit after incurring basilar skull fracture. Which complication of this injury does the nurse monitor for?

Answer 44

Hemorrhage

Rationale: This type of fracture may cause hemorrhage from damage to the internal carotid artery.

Question 45

When teaching about the pain associated with sickle cell crisis. It is correct to explain that the pain comes from:

Answer 45

Occlusion of arteries by sickle cell

Question 46

The most significant observations to be recorded when monitoring a patient with increased ICP are:

Answer 46

Increased systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP.

Question 47

The staff development trainer is preparing orientation materials for new staff hired to care for patients with seizure disorders. Which data are included in this presentation? Select all that apply.

Answer 47

Myoclonic
Tonic-clonic
Simple partial;

Question 48

Which of the following test does the nurse anticipate will be ordered for a patient to confirm a suspected diagnosis of epilepsy?

Answer 48

Electroencephalogram (EEG) and computed tomography (CT)

Question 49

The nurse is interviewing a patient who is newly admitted to the unit with a diagnosis of anemia. Which assessment findings does the nurse expect? Select all that apply

Answer 49

Headache
Concave appearance of the nails
Pallor of the ears
Dyspnea on exertion

Question 50

A patient is admitted for acute MI but the nurse notes that the traditional manifestations of ST elevation (STEMI) is not occurring. What other evidence for acute MI does the nurse expect to find in the patient (Select all that apply)

Answer 50

Positive Troponin markers
Non ST-elevation MI (non STEMI) on ECG

Question 51

A patient with sickle cell anemia is admitted to the unit in vaso-occlusive crisis (VOC). After the patient has been given the prescribed analgesic, which intervention is the priority to minimize the effects of the crisis?

Answer 51

IV Fluids

During a VOC bedrest is preferred, with the only exercise being passive range of motion. Because the kidneys of children with sickle cell anemia do not concentrate urine as well as do healthy kidneys, it is important to maintain adequate hydration. Hydration with IV fluids supplementing oral fluids can minimize the occurrence of a crisis because hemodilution helps prevent sickling.

Question 52

Proper procedure for administration of blood products

Answer 52

Check vital before hanging and before bringing it up from the blood bank to ensure the pt is ready to receive it.
Check expiration date
Check for cloudiness

Question 53

Tubing/administration guidelines for blood products administration

Answer 53

Y tubing- one side with blood the other side with NS
Filter will filter out big particles

Question 54

Adverse reaction of Blood administration

Answer 54

Fever
Chills
Hives
Itching
SOB
Anaphylaxis
Graft vs. Host- donor blood attacks the pt blood

Question 55

What are you going to do regularly for pt with sickle cell?

Answer 55

Sickle Tx: Prevention: Hydrated, prevent acidosis, hypoxia or cold (prevent anything that can trigger a vaso occlusive crisis)

Question 56

Why do we do staging for lymphoma?

Answer 56

Chemo protocol

Question 57

Hodgkins lymphoma

Answer 57

Reed-Sternberg cells: large, abnormal lymphocytes (a type of white blood cell) that may contain more than one nucleus
Localized node but can progress
Stage 1: in one node
Stage 4: in Cerebrospinal fluid and possibly bone marrow

Question 58

ALL characteristic

Answer 58

Immature lymphoblasts

Question 59

AML characteristic

Answer 59

Immature myloblast

Question 60

How do pt with Leukemia present?

Answer 60

Ecchymosis
Purpura
Petechiae
Fatigue and Malaise is from the Anemia
Less WBCs (granulocytes/ neutrophils/ mature WBC) -> neutropenia = major risk for infection

Question 61

Nursing Diagnosis for Leukemia

Answer 61

Risk for Infection
Risk for bleeding
Risk for Tumorlysis Syndrome -tumor cells bust which can create a massive fluid shift, acidosis, ^ uric acid lvl, > can hurt kidneys and make them acidotic

Question 62

Leukemia Complications

Answer 62

Bleeding
Anemia
Neutropenia
TLS - Tumor Lysis Syndrome

Question 63

Agent that can be used to help chemo cross the BBB and can use for pt with TBI to help with swelling

Answer 63

Mannitol