rev finals part 1 Flashcards
A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first?
a. Obtain two sets of blood cultures.
b. Administer the prescribed IV vancomycin (Vancocin).
c. Obtain central venous pressure (CVP) measurements.
d. Administer the prescribed IV norepinephrine (Levophed)
a. Obtain two sets of blood cultures.
(Blood cultures should be obtained before IV antibiotics are started. )
The emergency department nurse is triaging clients. Which client does the nurse assess most carefully for hypovolemic shock?
a. 15-year-old adolescent who plays high school basketball
b. 24-year-old computer specialist who has bulimia
c. 48-year-old truck driver who has a 40-pack-year history of smoking
d. 62-year-old business executive who travels frequently
b. 24-year-old computer specialist who has bulimia
(Hypovolemic shock can be caused by dehydration. )
A client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How does the nurse document this seizure activity?
a. Atonic seizure
b. Absence seizure
c. Myoclonic seizure
d. Tonic-clonic seizure
d. Tonic-clonic seizure
(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.)
The nurse is assessing a client with a history of absence seizures. Which clinical manifestation does the nurse assess for?
a. Automatisms
b. Intermittent rigidity
c. Sudden loss of muscle tone
d. Brief jerking of the extremities
a. Automatisms
Automatisms are characteristic of absence seizures.
The nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What is the nurse’s priority action?
a. Restrain the client’s extremities.
b. Turn the client’s head to the side.
c. Take the client’s blood pressure.
d. Place an airway into the client’s mouth.
b. Turn the client’s head to the side.
A client is actively experiencing status epilepticus. Which prescribed medication does the nurse prepare to administer?
a. Atropine
b. Lorazepam (Ativan)
c. Phenytoin (Dilantin)
d. Morphine sulfate
b. Lorazepam (Ativan)
The nurse is teaching a client who is newly diagnosed with epilepsy. Which statement by the client indicates a need for further teaching concerning the drug regimen?
a. “I will not drink any alcoholic beverages.”
b. “I will wear a medical alert bracelet.”
c. “I will let my doctor know about all of my prescriptions.”
d. “I can skip a couple of pills if they make me ill.”
d. “I can skip a couple of pills if they make me ill.”
A client with new-onset status epilepticus is prescribed phenytoin (Dilantin). After teaching the client about this treatment regimen, the nurse assesses the client’s understanding. Which statement indicates that the client understands the teaching?
a. “I must drink at least 2 liters of water daily.”
b. “This will stop me from getting an aura before a seizure.”
c. “I will not be able to be employed while taking this medication.”
d. “Even when my seizures stop, I will take this drug.”
d. “Even when my seizures stop, I will take this drug.”
The daughter of a client with Alzheimer’s disease asks, “Will the medication my mother is taking improve her dementia?” How does the nurse respond?
a. “It will help your mother live independently once more.”
b. “It is used to halt the advancement of Alzheimer’s disease but will not cure it.”
c. “It will provide a steady improvement in memory but not in problem solving.”
d. “It will not improve dementia but can help control emotional responses.”
d. “It will not improve dementia but can help control emotional responses.”
(Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer’s disease.)
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?
a. Palpate the area over the bladder for distention.
b. Place the client in the Trendelenburg position.
c. Administer oxygen via a nasal cannula.
d. Perform bilateral carotid massage.
a. Palpate the area over the bladder for distention.
(The client is manifesting symptoms of autonomic dysreflexia.)
Emergency medical services arrive 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?
a. Level of consciousness and orientation
b. Heart rate and rhythm
c. Muscle strength and reflexes
d. Respiratory pattern and airway
d. Respiratory pattern and airway
A client who experienced a spinal cord injury 1 hour ago is brought to the emergency department. Which prescribed medication does the nurse prepare to administer to this client?
a. Intrathecal baclofen (Lioresal)
b. Methylprednisolone (Medrol)
c. Atropine sulfate
d. Epinephrine (Adrenalin)
b. Methylprednisolone
(Methylprednisolone should be given within 8 hours of the injury.)
The nurse is caring for a client with a lower motor neuron lesion who wishes to achieve bladder control. Which intervention does the nurse implement to effectively stimulate the initiation of voiding for this client?
a. Stroking the inner aspect of the thigh
b. Intermittent catheterization
c. Digital anal stimulation
d. The Valsalva maneuver
d. The Valsalva maneuver
A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern. Which action does the nurse implement to assist in relieving this client’s constipation?
a. Pouring warm water over the perineum
b. Tapping the abdomen from left to right
c. Administering daily tap water enemas
d. Implementing a consistent daily time for elimination
d. Implementing a consistent daily time for elimination
A client with paraplegia 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 does the nurse respond?
a. “If you do not want to participate in the rehabilitation program, I will cancel the order.”
b. “Your doctor has helped many clients with your injury and has ordered a rehabilitation program to help you.”
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.”
c. “The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability.”
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 correctly understands the teaching?
a. “I will use my incentive spirometer every 2 hours while I’m awake.”
b. “I will not drink thick fluids to prevent choking.”
c. “I will take cough medicine to prevent excessive coughing.”
d. “I will position myself on my right side so I don’t aspirate.”
a. “I will use my incentive spirometer every 2 hours while I’m awake.”
A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication does the nurse prepare to administer?
a. Baclofen (Lioresal)
b. Interferon beta-1b (Betaseron)
c. Dantrolene sodium (Dantrium)
d. Methylprednisolone (Medrol)
d. Methylprednisolone (Medrol)
A client with multiple sclerosis is being treated with fingolimod (Gilenya). Which clinical manifestation alerts the nurse to an adverse effect of this medication?
a. Periorbital edema
b. Black tarry stools
c. Bradycardia
d. Vomiting after meals
c. Bradycardia
The nurse is preparing a client who has multiple sclerosis (MS) for discharge home from a rehabilitation center. The client has been prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which instruction does the nurse include in the teaching plan for the client?
a. “Take warm baths to promote muscle relaxation.”
b. “Avoid crowds and people with colds.”
c. “Use physical aids such as walkers as little as possible.”
d. “Stop using these medications when your symptoms improve.”
b. “Avoid crowds and people with colds.”
( these medications are immunosuppressive. Warm baths will exacerbate the MS symptoms, assistive devices )
Early manifestations of amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) are somewhat similar. Which clinical feature of ALS distinguishes it from MS?
a. Dysarthria
b. Dysphagia
c. Muscle weakness
d. Impairment of respiratory muscles
d. Impairment of respiratory muscles
In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, and this leads to respiratory compromise.
