Test #6 - NCLEX questions

Question 1

A client with no history of cardiovascular disease comes into the ambulatory clinic with flulike symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem?

1. “Have you ever had this pain before?”

2. “Can you describe the pain to me?”

3. “Does the pain get worse when you breathe in?”

4. “Can you rate the pain on a scale of 1-10, with 10 being the worst?”

Answer 1

3. “Does the pain get worse when you breathe in?”

Chest pain is assessed by using the standard pain assessment parameters. Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.

Question 2

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to:

1. Check the client status and lead placement
2. Press the recorder button on the electrocardiogram console.
3. Call the physician
4. Call a code blue

Answer 2

1. Check the client status and lead placement

Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention.

Question 3

A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following?

1. Seating the client with arm bared, supported, and at heart level.
2. Measuring the blood pressure after the client has been seated quietly for 5 minutes.
3. Using a cuff with a rubber bladder that encircles at least 80% of the limb.
4. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

Answer 3

4. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

BP should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured. Gauges other than a mercury sphygmomanometer should be calibrated every 6 months to ensure accuracy.

Question 4

A 60-year-old male client comes into the emergency department with complaints of crushing chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders include oxygen by NC at 4L/minute, blood work, chest x-ray, an ECG, and 2mg of morphine given intravenously. The nurse should first:

1. Administer the morphine
2. Obtain a 12-lead ECG
3. Obtain the lab work
4. Order the chest x-ray

Answer 4

1. Administer the morphine

Although obtaining the ECG, chest x-ray, and blood work are all important, the nurse’s priority action would be to relieve the crushing chest pain.

Question 5

The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?

1. Cancer
2. Hypertension
3. Liver disease
4. Myocardial infarction

Answer 5

4. Myocardial infarction

Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about one hour after a heart attack is experienced and peaks within 4 to 6 hours after infarction (Remember, less than 90 mg/L is normal).

Question 6

The most important long-term goal for a client with hypertension would be to:

1. Learn how to avoid stress
2. Explore a job change or early retirement
3. Make a commitment to long-term therapy
4. Control high blood pressure

Answer 6

3. Make a commitment to long-term therapy

Compliance is the most critical element of hypertensive therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management and weight management are important components of hypertension therapy, but the priority goal is related to compliance.

Question 7

Hypertension is known as the silent killer. This phrase is associated with the fact that hypertension often goes undetected until symptoms of other system failures occur. This may occur in the form of:

1. Cerebrovascular accident
2. Liver disease
3. Myocardial infarction
4. Pulmonary disease

Answer 7

1. Cerebrovascular accident

Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, the hypertension may go undetected. CVA’s can be related to long-term hypertension. Liver or pulmonary disease is generally not associated with hypertension. Myocardial infarction is generally related to coronary artery disease.

Question 8

Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician?

1. A change in the pattern of her pain
2. Pain during sex
3. Pain during an argument with her husband
4. Pain during or after an activity such as lawnmowing

Answer 8

1. A change in the pattern of her pain

The client should report a change in the pattern of chest pain. It may indicate increasing severity of CAD.

Question 9

The physician refers the client with unstable angina for a cardiac catherization. The nurse explains to the client that this procedure is being used in this specific case to:

1. Open and dilate the blocked coronary arteries
2. Assess the extent of arterial blockage
3. Bypass obstructed vessels
4. Assess the functional adequacy of the valves and heart muscle.

Answer 9

2. Assess the extent of arterial blockage

Cardiac catherization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage, A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catherization results.

Question 10

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug’s principle effects are produced by:

1. Antispasmotic effect on the pericardium
2. Causing an increased mycocardial oxygen demand
3. Vasodilation of peripheral vasculature
4. Improved conductivity in the myocardium

Answer 10

3. Vasodilation of peripheral vasculature

Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

Question 11

The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including:

1. Headache
2. High blood pressure
3. Shortness of breath
4. Stomach cramps

Answer 11

1. Headache

Because of the widespread vasodilating effects, nitroglycerin often produces such side effects as headache, hypotension, and dizziness. The client should lie or shit down to avoid fainting. Nitro does not cause shortness of breath or stomach cramps.

Question 12

Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs?

1. Take one tablet every 2 to 5 minutes until the pain stops.
2. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes.
3. Take one tablet, then an additional tablet every 5 minutes for a total of 3 tablets. Call the physician if pain persists after three tablets.
4. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician.

Answer 12

3. Take one tablet, then an additional tablet every 5 minutes for a total of 3 tablets. Call the physician if pain persists after three tablets.

The correct protocol for nitroglycerin used involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of 3 tablets. Sublingual nitroglycerin appears in the blood stream within 2 to 3 minutes and is metabolized within about 10 minutes.

Question 13

Which of the following blood tests is most indicative of cardiac damage?

1. Lactate dehydrogenase
2. Complete blood count (CBC)
3. Troponin I
4. Creatine kinase (CK)

Answer 13

3. Troponin I

Levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin levels aren’t detectable in people without cardiac injury.

Question 14

Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage?

1. Cardiac catherization
2. Cardiac enzymes
3. Echocardiogram
4. Electrocardiogram (ECG)

Answer 14

4. The ECG

is the quickest, most accurate, and most widely used tool to determine the location of myocardial infarction. Cardiac enzymes are used to diagnose MI but can’t determine the location. An echocardiogram is used most widely to view myocardial wall function after an MI has been diagnosed. Cardiac catherization is an invasive study for determining coronary artery disease and may also indicate the location of myocardial damage, but the study may not be performed immediately.

Question 15

Which of the following types of pain is most characteristic of angina?

1. Knifelike
2. Sharp
3. Shooting
4. Tightness

Answer 15

4. Tightness

The pain of angina usually ranges from a vague feeling of tightness to heavy, intense pain. Pain impulses originate in the most visceral muscles and may move to such areas as the chest, neck, and arms.

Question 16

One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect?

1. Hypocalcemia
2. Hypermagnesemia
3. Hypokalemia
4. Hypernatremia

Answer 16

3. Hypokalemia

Furosemide is a potassium-depleting diuretic than can cause hypokalemia. In turn, hypokalemia increases myocardial excitability, leading to ventricular tachycardia.

Question 17

Following a treadmill test and cardiac catheterization, the client is found to have coronary artery disease, which is inoperative. He is referred to the cardiac rehabilitation unit. During his first visit to the unit he says that he doesn’t understand why he needs to be there because there is nothing that can be done to make him better. The best nursing response is:

1. “Cardiac rehabilitation is not a cure but can help restore you to many of your former activities.”
2. “Here we teach you to gradually change your lifestyle to accommodate your heart disease.”
3. “You are probably right but we can gradually increase your activities so that you can live a more active life.”
4. “Do you feel that you will have to make some changes in your life now?”

Answer 17

1. “Cardiac rehabilitation is not a cure but can help restore you to many of your former activities.”

Such a response does not have false hope to the client but is positive and realistic. The answer tells the client what cardiac rehabilitation is and does not dwell upon his negativity about it.

Question 18

A client enters the ER complaining of chest pressure and severe epigastric distress. His VS are 158/90, 94, 24, and 99*F. The doctor orders cardiac enzymes. If the client were diagnosed with an MI, the nurse would expect which cardiac enzyme to rise within the next 3 to 8 hours?

1. Creatine kinase (CK or CPK)
2. Lactic dehydrogenase (LDH)
3. LDH-1
4. LDH-2

Answer 18

1. Creatine kinase (CK, formally known as CPK)

It rises in 3-8 hours if an MI is present. When the myocardium is damaged, CPK leaks out of the cell membranes and into the blood stream. Lactic dehydrogenase rises in 24-48 hours, and LDH-1 and LDH-2 rises in 8-24 hours.

Question 19

When teaching a patient why spironolactone (Aldactone) and furosemide (Lasix) are prescribed together, the nurse bases teaching on the knowledge that:

1. Moderate doses of two different types of diuretics are more effective than a large dose of one type
2. This combination promotes diuresis but decreases the risk of hypokalemia
3. This combination prevents dehydration and hypovolemia
4. Using two drugs increases osmolality of plasma and the glomerular filtration rate

Answer 19

2. This combination promotes diuresis but decreases the risk of hypokalemia

Spironolactone is a potassium-sparing diuretic; furosemide is a potassium-loosing diuretic. Giving these together minimizes electrolyte imbalance.

Question 20

Which laboratory level is a common finding associated with peripheral vascular disease (PVD)?

1. Low serum albumin
2. Potassium level of 3.1
3. High serum lipids
4. Total calcium level of 15 mg/dL

Answer 20

3. High serum lipids

High serum lipids, especially the low-density (LDL) and very-low density (VLDL) types, are associated with peripheral vascular disease (PVD). Other listed laboratory findings have not been associated with PVD.

Question 21

For a client experiencing symptoms of claudication, care plan activities should avoid promoting which of the following situations?

1. Oxygen supply exceeds muscle demand
2. Oxygen is absent
3. Oxygen supply and muscle demand are equivalent
4. Oxygen supply is inadequate for muscle demand

Answer 21

3. Oxygen supply and muscle demand are equivalent

Clients who experience claudication complain of aching, cramping, and weakness. These signs indicate that oxygen supply is inadequate for muscle demand. Activities that aggravate these symptoms should be avoided.

Question 22

A 50-year-old client with a history of smoking is experiencing symptoms of claudication in his right calf during exercise, in which he participates daily. Which of the following assessment details requires further evaluation?

1. Ankle brachial index of 0.65
2. Blood pressure 138/78
3. Heart rate 54
4. SpO2 of 94% on room air

Answer 22

1. Ankle brachial index of 0.65

An ankle brachial index is found by dividing the systolic blood pressure in the ankle by the systolic blood pressure in the arm. An index of 0.65 indicates that the pressure in the leg is less than that of the arm, and is suggestive of moderate vascular disease in this client. The low heart rate is a normal finding in a client who regularly exercises. The SpO2 level is normal for a smoker.

Question 23

The nurse diagnoses an overweight client taking wafarin (Coumadin) with Ineffective tissue perfusion related to decreased arterial blood flow. Which teaching point would not be appropriate to include in the plan of care for this client?

1. Inspecting skin daily
2. Encouraging a reduced-calorie, reduced-fat diet
3. Limiting activities of daily living (ADL)
4. Using an electric razor

Answer 23

3. Limiting activities of daily living (ADL)

Question 24

The nurse notes bilateral ankle edema on a client diagnosed with peripheral vascular disease (PVD). The nurse knows this is due to:

1. Decreased blood volume
2. Increased venous pressure
3. Decreased muscular activity
4. Increased venous blood flow

Answer 24

2. Increased venous pressure

Decreased blood flow from PVD can result in increased venous pressure, which causes fluid to filter out of the capillaries into the interstitial space.

Question 25

The pain of intermittent claudication is expected when arterial occlusion reaches:

1. 20%
2. 40%
3. 50%
4. 95%

Answer 25

3. 50%

Intermittent pain that is relieved with rest is expected when arterial occlusion reaches 50-75%. A 95% blockage would exhibit with additional signs such as pallor, coolness and absence of pulses in the affected limb.

Question 26

A client with heart failure and peripheral vascular disease has 4+ edema in his left ankle that extends to mid-calf. He is currently sitting on the side of his bed with his feet in a dependent position. Which goal would be the priority at this time?

1. Resume normal respirations
2. Reduce cardiac stress
3. Prevent injury to lower extremity
4. Decrease venous congestion

Answer 26

4. Decrease venous congestion

Venous congestion due to altered blood flow is the likely cause of this client’s edema. The goal should be to decrease venous congestion by elevating the affected limb. No indication is given that this client is in respiratory distress or has abnormal cardiac stress at this time. The nurse should prevent injury to the lower extremity, but this is not the priority.

Question 27

Buerger’s disease is characterized by all of the following except:

1. Arterial thrombosis formation and occlusion
2. Lipid deposits in the arteries
3. Redness or cyanosis in the limb when it is dependent
4. Venous inflammation and occlusion

Answer 27

2. Lipid deposits in the arteries

Question 28

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for:

1. At least 12 hours
2. The first 24 hours
3. 2-3 days
4. 1 week

Answer 28

3. 2-3 days

Question 29

Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike’s symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably:

1. Alteration in tissue perfusion related to compromised circulation
2. Dysfunctional use of extremities related to muscle spasms
3. Impaired mobility related to stress associated with pain
4. Impairment in muscle use associated with pain on exertion.

Answer 29

1. Alteration in tissue perfusion related to compromised circulation

Question 30

A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for:

1. Familial tendency toward peripheral vascular disease
2. Smoking history
3. Recent exposures to allergens
4. History of insect bites

Answer 30

2. Smoking history

The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests Buerger’s disease. This is an uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component.

Question 31

A nurse has an order to begin administering warfarin sodium (coumadin) to a client. While implementing this order, the nurse ensures that which of the following medications is available on the nursing unit as the antidote for Coumadin?

1. Vitamin K
2. Aminocaproic acid
3. Potassium chloride
4. Protamine sulfate

Answer 31

1. Vitamin K

The antidote to warfarin (Coumadin) is Vitamin K and should be readily available for use if excessive bleeding or hemorrhage should occur.

Question 32

In preparation for discharge of a client with arterial insufficiency and Raynaud’s disease, client teaching instructions should include:

1. Walking several times each day as an exercise program.
2. Keeping the heat up so that the environment is warm
3. Wearing TED hose during the day
4. Using hydrotherapy for increasing oxygenation

Answer 32

2. Keeping the heat up so that the environment is warm

The client’s instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase pain.

Question 33

A client comes to the outpatient clinic and tells the nurse that he has had legs pains that began when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for?

1. An acute obstruction in the vessels of the legs
2. Peripheral vascular problems in both legs
3. Diabetes
4. Calcium deficiency

Answer 33

2. Peripheral vascular problems in both legs

Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking.

Question 34

A nurse is teaching a wellness class and is covering the warning signs of stroke. A patient asks, “What is the most important thing for me to remember?” Which is an appropriate response by the nurse?

1. “Know your family history.”
2. “Keep a list of your medications.”
3. “Be alert for sudden weakness or numbness.”
4. “Call 911 if you notice a gradual onset of paralysis or confusion.”

Answer 34

“Be alert for sudden weakness or numbness.”

Rationale: Warning signs of stroke include sudden weakness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.

Question 35

A patient was diagnosed with a left cerebral hemorrhage. Which topics are most appropriate for the nurse to include in patient and family teaching?

Select all that apply.

1. how to use a sign board
2. transfer techniques
3. information about impulse control
4. time adjustment to complete activities
5. safety precautions for transferring

Answer 35

1. how to use a sign board
2. transfer techniques
3. safety precautions for transferring

Rationale: The left cerebral hemisphere is responsible for the language center, calculation skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain damage. The patient also might display overcautious behavior and might be slow to respond or complete activities. Transfer techniques would apply regardless of the side involved. Impulse control problems can arise with right-sided involvement.

Question 36

A post-stroke patient is going home on oral Coumadin (warfarin). During discharge teaching, which statement by the patient reflects an understanding of the effects of this medication?

1. “I will stop taking this medicine if I notice any bruising.”
2. “I will not eat spinach while I’m taking this medicine.”
3. “It will be OK for me to eat anything, as long as it is low fat.”
4. “I’ll check my blood pressure frequently while taking this medication.”

Answer 36

2. “I will not eat spinach while I’m taking this medicine.”

Rationale: Warfarin is a vitamin K antagonist. Green, leafy vegetables contain vitamin K, and will therefore interfere with the therapeutic effects of the drug. Bruising is a common side effect, and the drug should not be stopped unless by prescriber order. Low-fat foods do not interfere with warfarin therapy, which is not prescribed to affect the blood pressure.

Question 37

A patient is admitted with signs of a stroke (CVA). On admission, vital signs were blood pressure 128/70, pulse 68, and respirations 20. Two hours later the patient is not awake, has a blood pressure of 170/70, pulse 52, and the left pupil is now slower than the right pupil in reacting to light. These findings suggest which of the following?

1. impending brain death
2. decreasing intracranial pressure
3. stabilization of the patient’s condition
4. increased intracranial pressure

Answer 37

4. increased intracranial pressure

Rationale: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP). This is an emergency situation that requires notification of the physician. This is an emergency situation that requires intervention as the patient’s condition is becoming more unstable. Brain death is diagnosed by lack of brain waves and inability to maintain vital function.

Question 38

A hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may have had a stroke (CVA). What is the nurse’s priority intervention?

1. Move the patient to the critical care unit.
2. Assess blood pressure.
3. Assess the airway and breathing.
4. Observe urinary output.

Answer 38

3. Assess the airway and breathing.

Rationale: In any unconscious patient, the airway must be protected. Assessment of the current airway and breathing status is of highest priority and will continue to be. Blood pressure and output monitoring as well as ensuring appropriate level of care are important interventions, but assessment of the patient’s ability to maintain an airway is the most vital.

Question 39

The family of a patient who has had a brain attack (CVA) asks if the patient will ever talk again. The nurse should do which of the following?

1. Explain that the patient’s speech will return to normal with time.
2. Explain that it is difficult to know how far the patient will progress.
3. Tell the family that nurses cannot discuss such issues. Tell them to ask the physician.
4. Tell the family what they see today is all they can expect.

Answer 39

2. Explain that it is difficult to know how far the patient will progress.

Rationale: Therapeutic communication is needed. It is important to allow hope but be honest by not promising progress, since no one knows how much the patient will improve. Progress may depend on the extent and the areas affected. The nurse does not know that speech will return in time. It is not therapeutic to tell the family to ask the physician, and it does not display a professional, caring attitude.

Question 40

The nurse is teaching regarding risk factors for stroke (CVA). The greatest risk factor is which of the following?

1. diabetes
2. heart disease
3. renal insufficiency
4. hypertension

Answer 40

4. hypertension

Rationale: Hypertension is the greatest risk factor for stroke, and should be controlled. Diabetes, heart disease, and renal insufficiency can all lead to stroke, however hypertension is the greatest risk.

Question 41

The nurse recognizes that the most common type of brain attack (CVA) is related to which of the following?

1. ischemia
2. hemorrhage
3. headache
4. vomiting

Answer 41

1. ischemia

Rationale: Eighty percent of all strokes are caused by ischemia. Hemorrhagic strokes are less common than ischemic strokes. Headache and vomiting may be symptoms associated with CVA, but not common causes

Question 42

When caring for a patient admitted post-stroke (CVA) who has altered consciousness, the nurse should place the patient in which position?

1. side-lying
2. supine
3. prone
4. semi-Fowler’s

Answer 42

1. side-lying

The side-lying position is the safest position to allow adequate drainage of fluids without aspiration.

Question 43

Indicate whether the following manifestations of a stroke are more likely to occur with right brain damage or left brain damage?

a. Aphasia
b. Left homonymous hemianopia
c. Agnosia
d. Quick and impulsive behavior
e. Inability to remember words
f. Neglect of the left side of body

Answer 43

a. Aphasia Left side
b. Left homonymous hemianopia Right side
c. Agnosia Right side
d. Quick and impulsive behavior Right side
e. Inability to remember words Left side
f. Neglect of the left side of body Right side

Question 44

A nursing intervention that is indicated for the patient with hemiplegia is:

a. the use of a footboard to prevent plantar flexion
b. immobilization of effected arm against the chest with a sling
c. positioning the pt in bed with every joint lower than the joint proximal to it
d. having the pt perform passive ROM of the affected limb with the unaffected limb

Answer 44

d. having the pt perform passive ROM of the affected limb with the unaffected limb

Question 45

The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address?

a. The patient smokes a pack of cigarettes daily.
b. The patient’s blood pressure (BP) is chronically between 150/80 to 170/90 mm Hg.
c. The patient works at a desk and relaxes by watching television.
d. The patient is 25 pounds above the ideal weight.

Answer 45

b. The patient’s blood pressure (BP) is chronically between 150/80 to 170/90 mm Hg.

Hypertension is the most modifiable risk factor

Question 46

A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first?

a. Noncontrast computed tomography (CT) scan
b. Chest radiograph
c. Complete blood count (CBC)
d. Electrocardiogram (ECG)

Answer 46

a. CT Scan

Rapid screening is needed before giving thrombolytic enzymes. The sooner is given, the less the brain area affected

Question 47

Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?

a. The patient has atrial fibrillation.
b. The patient has dysphasia.
c. The patient states, “I suddenly developed a terrible headache.”
d. The patient has a history of brief episodes of right hemiplegia.

Answer 47

C. The patient states, “I suddenly developed a terrible headache”

A sudden-onset headache is typical of a hemorrhage and aspirin is contraindicated

Question 48

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient’s clinical manifestations, it is most important the nurse assess the patient’s

a. ability to follow commands.
b. visual fields.
c. right-sided reflexes.
d. emotional state.

Answer 48

a. Ability to follow commands

It is important to obtain baseline data of ability to follow commands because the patient with a left sided brain stroke may also have difficulty with comprehension and language use

Question 49

The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to

a. ask simple questions that the patient can answer with “yes” or “no.”
b. develop a list of words that the patient can read and practice reciting.
c. have the patient practice facial and tongue exercises to improve motor control necessary for speech.
d. prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner.

Answer 49

a. ask simple questions that the patient can answer with “yes” or “no”

Communication will be facilitated and less frustrating to the patient when questions require a “yes” or “no” response

Question 50

A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is

a. risk for impaired skin integrity related to immobility.
b. disturbed sensory perception related to brain injury.
c. risk for aspiration related to inability to protect airway.
d. impaired physical mobility related to weakness.

Answer 50

C. Risk for aspiration related to inability to protect airway

Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

Question 51

The type of immunity achieved through the administration of vaccine is called:

1. active immunity
2. passive immunity
3. titer
4. vaccine

Answer 51

1. Active Immunity

Rationale: Active Immunity occurs when the patient has received the vaccine. Passive immunity is achieved by directly administering antibodies to a patient. A titer is a measurement of the amount of antibody produced after a vaccine.

Question 52

The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client’s risk factors associated with the allergy, the nurse questions the client about an allergy to which food item?

Eggs

Milk

Yogurt

Bananas

Answer 52

Bananas

Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be due to a possible cross-reaction between the food and the latex allergen. The incorrect options are unrelated to latex allergy.

Question 53

A nurse is assisting in developing a plan of care for a client with immunodeficiency. The nurse understands that which problem is a priority for the client?

Infection

Inability to cope

Lack of information about the disease

Feeling uncomfortable about body changes

Answer 53

Infection

The client with immunodeficiency has inadequate or an absence of immune bodies and is at risk for infection. The priority problem is infection. The question presents no data indicating that options 2, 3, or 4 are a problem.

Question 54

Metoprolol (Toprol XL) is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension initially treated with Furosemide (Lasix) and Ramipril (Altace). An expected therapeutic effect is:

1. Decrease in heart rate.
2. Lessening of fatigue.
3. Improvement in blood sugar levels.
4. Increase in urine output.

Answer 54

1. Decrease in heart rate.

The effect of a beta blocker is a decrease in heart rate, contractility, and afterload, which leads to a decrease in blood pressure. The client at first may have an increase in fatigue when starting the beta blocker. The mechanism of action does not improve blood sugar or urine output.

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Question 55

The nurse teaches a client, who has recently been diagnosed with hypertension, about dietary restrictions: a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client’s needs?

1. Mixed green salad with blue cheese dressing, crackers, and cold cuts.
2. Ham sandwich on rye bread and an orange.
3. Baked chicken, an apple, and a slice of white bread.
4. Hot dogs, baked beans, and celery and carrot sticks.

Answer 55

3. Baked chicken, an apple, and a slice of white bread.

Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of all types are complex and difficult to implement with clients who are basically asymptomatic.

Question 56

An exercise program is prescribed for the client with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program?

1. Giving the client a written exercise program.
2. Explaining the exercise program to the client’s spouse.
3. Reassuring the client that he or she can do the exercise program.
4. Tailoring a program to the client’s needs and abilities.

Answer 56

4. Tailoring a program to the client’s needs and abilities.

Tailoring or individualizing a program to the client’s lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client’s spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program.

Question 57

The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan?

1. Review the negative effects of smoking on the body.
2. Discuss the effects of passive smoking on environmental pollution.
3. Establish the client’s daily smoking pattern.
4. Explain how smoking worsens high blood pressure.

Answer 57

3. Establish the client’s daily smoking pattern.

A plan to reduce or stop smoking begins with establishing the client’s personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.

Question 58

Essential hypertension would be diagnosed in a 40-year-old male whose blood pressure readings were consistently at or above which of the following?

1. 120/ 90 mm Hg.
2. 130/ 85 mm Hg.
3. 140/ 90 mm Hg.
4. 160/ 80 mm Hg.

Answer 58

3. 140/ 90 mm Hg.

American Heart Association standards define hypertension as a consistent systolic blood pressure level greater than 140 mm Hg and a consistent diastolic blood pressure level greater than 90 mm Hg.

Question 59

The client has had hypertension for 20 years. The nurse should assess the client for?

1. Renal insufficiency and failure.
2. Valvular heart disease.
3. Endocarditis.
4. Peptic ulcer disease.

Answer 59

1. Renal insufficiency and failure.

Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication. Valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension.