Quiz 5 Flashcards
A nurse is caring for a client who has had a stroke involving the right hemisphere. What alterations in function should the nurse expect?
Inability to recognize his family members
A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client’s vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/ min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?
A. Transient ischemic attack (TIA)
B. Hemorrhagic stroke
C. Thrombotic stroke
D. Embolic stroke
B. Hemorrhagic stroke
A nurse at a rehabilitation center is planning care for a client who had a left CVA three weeks ago. Which of the following goals should the nurse include in the client’s rehab program?
A. establish ability to communicate effectively
B. compensate for loss of depth perception
C. learn to control impulse behavior
D. improve left sided motor function
A. establish ability to communicate effectively
A nurse is instructing a client’s family members about feeding safety for a client who has dysphagia. What instruction should the nurse include?
Encourage the client to take small bites.
A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?
Remind the client to look for food on the left side of the tray.
A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?
A. “Incorporate nonverbal cues in the conversation.”
B. “Ask multiple choice questions as part of the conversation.”
C. “Use a higher-pitched tone of voice when speaking.”
D. “Use simple, child-like statements when speaking.”
A. “Incorporate nonverbal cues in the conversation.”
A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
A. poor impulse control
B. unable to discriminate words and letters
C. deficits in the right visual field
D. motor retardation
A. poor impulse control
A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?
A. Impaired sense of humor
B. Loss of depth perception
C. Poor judgement
D. Intellectual impairment
D. Intellectual impairment
A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first?
A. Provide chest physiotherapy
B. Perform oropharyngeal suction
C. Encourage deep-breathing and coughing
D.Assist the client with ambulation
C. Encourage deep-breathing and coughing
A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse take?
A. Obtain IV access
B. Keep the lights on while the client is sleeping
C. Place the client’s bed in the highest position
D. keep a padded tongue blade available at the client’s bedside
A. Obtain IV access
A nurse is caring for an adolescent client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the client’s parent is the nurse’s priority?
A. “He takes a 2-hr nap every day after school.”
B. “ He says he feels sick to his stomach after taking this medication.”
C. “He has so many new bruises on his body.”
D. “He says his mouth is always dry.”
B. “ He says he feels sick to his stomach after taking this medication.”
A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?
A. “I will notify my doctor before taking any other medications.”
B. “I have made an appointment to see my dentist next week.”
C. “I know that I cannot switch brands of this medication.”
D. “I’ll be glad when I can stop taking this medicine.”
D. “I’ll be glad when I can stop taking this medicine.”
A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. which of the following actions is most likely to facilitate resolution of the headaches?
A. administer pain medication
B. darken the clients room and close the door
C. increased fluid intake
D. elevate the head of bed to 30°
C. increased fluid intake
A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse?
A. Chest tightness
B. Skin flushing
C. Tingling feelings
D. Warm sensation
a. Chest tightness
When a patient experiences a generalized tonic-clonic seizure in the emergency department after a head injury, all of the following orders are received. Which one will the nurse implement first?
a. Send to radiology for computed tomography (CT) scan.
b. Administer Benzodiazepine - midazolam (Versed).
c. Check capillary blood glucose.
d. Monitor level of consciousness (LOC).
b. Administer Benzodiazepine - midazolam (Versed).
