Nursing Assessment Questions and Interventions for Neurological Disorders, Exams of Nursing

Download Nursing Assessment Questions and Interventions for Neurological Disorders and more Exams Nursing in PDF only on Docsity! 1.0 M8E_N213 1.25/1.25 points (graded) Which assessment data should the RN collect first from the client brought to the Emergency Department with confusion and a decreased level of consciousness? History of drug or alcohol abuse. Current medications. Family medical history. Onset of symptoms correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 2.0 M8E_N213 1.25/1.25 points (graded) The RN uses the Glasgow Coma Scale (GCS) to assess a client with an acute brain injury and notes a score of four (4). Which intervention is a priority for this client? Maintain the airway. correct Improve extremity range of motion. Promote skin integrity. Prevent injury. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 3.1 M8E_N213 1.25/1.25 points (graded) An RN is caring for a client with Multiple Sclerosis, who is experiencing weakness in their extremities. Which of the following would be an appropriate expected outcome for a client with Impaired physical mobility? The client will: Participate in strenuous exercise as tolerated. Apply orthotics to reduce contractures. The client will use assistive devices effectively. correct Take a hot bath daily to limit spasticity. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 4.0 M8E_N213 1.25/1.25 points (graded) Which assessment indicates to the RN that the prescribed acetylcholinesterase inhibitor is effective for the client diagnosed with myasthenia gravis? Denies nausea when eating. Reports no muscle pain. Blinks eyes without tearing. Feeds self independently. correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 5.0 M8E_N213 1.25/1.25 points (graded) Which information should the RN include in the teaching plan for the client with a new diagnosis of myasthenia gravis? Select all that apply Schedule rest periods throughout the day. Take medications on a regular schedule. Use scatter rugs on bare floor. Avoid soft foods in gravy or sauces. Sit upright during meals. correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) What is the priority nursing intervention when providing care for a client experiencing status epilepticus? Time the length of the seizure. Maintain the airway. correct Administer medication IV stat. Contact the heath care provider. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 12.0 M8E_N213 1.25/1.25 points (graded) Which statement made by the client with a new prescription for phenytoin indicates to the RN that more teaching is needed? “My spouse will have to drive me to my next doctor’s appointment.” “My urine may turn reddish brown in color.” “I will use a soft bristle toothbrush.” “I need to take this medication on an empty stomach.” correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 13.0 M8E_N213 0/1.25 points (graded) Which information should the RN include when teaching a pediatric client about a fiberglass forearm cast? Select all that apply Ask the child to wiggle their fingers every 4 hours. Do not use magic markers for autographs. Elevate the arm on a pillow for the first day. Swimming is allowed with a fiberglass cast. Blow cool air down the cast if itching occurs. incorrect You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Incorrect (0/1.25 points) 14.0 M8E_N213 1.25/1.25 points (graded) Which intervention by the unlicensed assistive personnel (UAP) caring for the client with right hemiparesis requires the RN to intervene? The UAP places a hand under the right axilla to move the client up in bed. correct The UAP praises the client for performing ADLs independently. The UAP positions the client supine with the head turned to one side. The UAP places a gait belt around the client’s waist prior to ambulating. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 15.0 M8E_N213 1.25/1.25 points (graded) Which assessment is a priority for the RN to perform while the client diagnosed with an ischemic stroke is receiving tissue plasminogen activator (t-PA)? Urine output. Signs of active bleeding. correct Blood pressure. Skin turgor. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 16.0 M8E_N213 1.25/1.25 points (graded) Which nursing intervention is a priority when caring for a client diagnosed with Guillain-Barre’ Syndrome? Encourage use of incentive spirometry. correct Measure strict intake and output. Medicate for pain as needed. Turn and position every two hours. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 17.0 M8E_N213 1.25/1.25 points (graded) Which nursing intervention is a priority for the client diagnosed with diffuse axonal injury (DAI)? Administer opioids to control restlessness. Keep the head of the bed elevated about 30 degrees. correct Initiate supplemental feedings to increase available calories Provide passive range of motion exercises to extremities. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 18.0 M8E_N213 1.25/1.25 points (graded) Which information should the RN include in a community presentation to prevent head and spinal cord injuries? Children should not eat while in a car for fear of choking. Helmets should be worn when skateboarding, skiing or riding bicycles. correct Parents should not sleep with infants. Children under age 12 should be restrained in the front seat of the car. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 19.0 ME8_N213 Which nursing intervention is a priority when a client who arrives in the Emergency Department awake and conversant after a brief loss of consciousness following a head injury becomes restless, agitated and confused? Notify the primary care provider. correct Request a CT scan of the head. Administer lorazepam intravenously. Prepare for endotracheal intubation. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 25.0 M8E_N213 1.25/1.25 points (graded) Which task would not be appropriate for the RN to delegate to a UAP or LPN for a client who has impaired physical mobility? Asking the UAP to provide the client with non-skid socks for ambulation. Asking the LPN to ambulate the client to the bathroom with a walker. Asking the LPN to administer pain medication to the client. Asking the UAP to assess and evaluate the client’s response to pain medication. correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 26.0 M8E_N213 1.25/1.25 points (graded) Which statement made by the client using ibuprofen to manage the pain of osteoarthritis indicates to the RN the need for additional teaching? “I should take this medication with meals or a snack.” “I will avoid drinking wine while taking this medication.” “I need to call my physician if my feet are swollen in the morning.” “My risk for a heart attack will decrease.” correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 27.0 M8E_N213 0/1.25 points (graded) Which outcome would the RN identify for the client who is one day post-operative total knee replacement with the nursing diagnosis Risk for peripheral neurovascular dysfunction? Ambulate independently for 50 feet Demonstrates capillary refill less than 3 seconds on the toes of both feet Report decreased pain at the operative site incorrect Wears antiembolism stockings at all times You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Incorrect (0/1.25 points) 28.1 M8E_N213 1.25/1.25 points (graded) Which interventions should the RN implement for the postoperative client with a hip arthroplasty? Select all that apply. Assist the client to cross the legs. Flex the hip less than 90 degrees. Always turn the clent onto the operative side. Place a pillow under affected leg. Place abductor pillow between legs. correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 29.0 M8E_N213 1.25/1.25 points (graded) Which intervention should the RN implement first for the client with a fractured femur who is suspected of having fat embolism syndrome (FES)? Encourage respiratory hygiene exercises. Administer methyl prednisone intravenously. Initiate supplemental oxygen. correct Assess breath sounds bilaterally. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 30.0 M8E_N213 1.25/1.25 points (graded) Which response by the RN is appropriate when the client diagnosed with gout asks about using aspirin to relieve pain in the left great toe? “It is not recommended as a high dose would be necessary.” “Aspirin can lead to increased levels of uric acid in the body.” correct “Aspirin can interfere with the action of the other medications.” “It is appropriate to take aspirin as it will relieve the pain.” You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 31.0 M8E_N213 1.25/1.25 points (graded) Which intervention is a priority when the RN administers alendronate? Administer the medication first thing in the morning. Instruct the client to chew each tablet. Have the client remain upright for 30 minutes after administration. correct Encourage the client to participate in weight bearing exercise. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 32.0 M8E_N213 1.25/1.25 points (graded) Place right foot and left crutch forward, then left foot and right crutch forward. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Incorrect (0/1.25 points) 38.0 M8E_N213 0/1.25 points (graded) The RN would teach a client newly diagnosed with gout to avoid which of the following foods? Select all that apply. White bread Fried eggs Oatmeal Shrimp Chicken incorrect You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Incorrect (0/1.25 points) 39.0 M8E_N213 1.25/1.25 points (graded) Which task can the RN delegate to the LPN when providing care for a client diagnosed with a stroke? Perform a neurological assessment. Administer the prescribed anticoagulant subcutaneously. correct Feed the client the first meal since admission. Teach the client to tuck the chin when swallowing. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 40.0 M8E_N213 1.25/1.25 points (graded) Which instruction should the RN include in the teaching plan for the client diagnosed with systemic lupus erythematosus (SLE) who is experiencing fatigue? Encourage aerobic exercise at least five days a week. Develop a plan for managing activities of daily living. correct Limit the client’s dependence on assistive devices. Reduce the client’s intake of carbohydrates You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 41.0 M8E_N213 1.25/1.25 points (graded) Which assessment would indicate to the RN that fat embolism syndrome may have developed in a client with multiple fractures of the lower extremities? Decrease in urine output to less than 30 mL per hour. Cool dry extremities upon palpation. Generalized pain in the calves. Tachypnea and hypoxia. correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 42.1 M8E_N213 1.25/1.25 points (graded) Which nursing intervention is most appropriate for a client with Parkinson Disease, who has been taking carbidopa-levodopa for two weeks and reports the medication has been ineffective? Ensure that the client is eating a diet high in protein and vitamin B6 (pyridoxine). Contact the physician to change the dose of the medication. Teach the client that the medication can cause psychosis. Remind the client that it may take up to two months to notice any effectiveness. correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 43.0 M8E_N213 1.25/1.25 points (graded) Which problem does the RN foresee in adherence to the treatment plan for a school age child diagnosed with scoliosis that needs to wear a brace for 23 hours every day? Difficulty in putting the brace on. Not understanding what the brace is for. Self-consciousness about appearance. correct Pain from the brace. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 44.0 M8E_N213 1.25/1.25 points (graded) Which is the most appropriate response for the RN to make to the parents of a child diagnosed with Duchenne muscular dystrophy? “Because he is cognitively impaired, there is no need to deal with the prognosis.” “Throughout this disease, we will focus on maximizing his abilities and his comfort level.” correct “Nothing is likely to happen for a long time; we can deal with it when it comes.” “There is not enough known about this disease to know what will happen.” You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 45.0 M8E_N213 1.25/1.25 points (graded) Which intervention would the RN implement to promote peripheral perfusion for the client that has had total knee replacement surgery? Instruct the client to flex both feet and uninvolved joints every hour. correct Keep the leg below the level of the heart. 1.25/1.25 points (graded) The RN is caring for a client diagnosed with a left hemispheric stroke. What assessment finding should the RN expect to assess ? Impulsive behavior. Lack of awareness of deficits. Receptive aphasia. correct Left visual field deficit. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 52.0 M8E_N213 0/1.25 points (graded) Which action by the unlicensed assistive personnel (UAP) requires immediate intervention by the RN? Providing a walker for the client that is 3 days post-operative left total hip replacement. incorrect Encouraging the client with an external fixation device to use a trapeze to change position. Allowing the client with expressive aphasia to write the answer to a question. Placing a pillow under the residual limb of a client with an above the knee amputation. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Incorrect (0/1.25 points) 53.0 M8E_N213 1.25/1.25 points (graded) Which electrolyte imbalances should the RN monitor in a client receiving mannitol to manage increased intracranial pressure? Select all that apply. Hypocalcemia Hypernatremia Hypokalemia Hypermagnesemia Hypophosphatemia correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 54.0 M8E_N213 0/1.25 points (graded) Which intervention should the RN implement for the client that reports severe pain in the left foot, two days after a left below the knee amputation? Explain that the client’s left foot has been amputated. incorrect Request a consultation with a psychiatrist. Place the client’s residual limb in a dependent position. Medicate the client with the prescribed opioid analgesic. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Incorrect (0/1.25 points) 55.0 M8E_N213 0/1.25 points (graded) A client presents to the Emergency Department with an open fracture of the right radius. What actions would the RN need to complete? Select all that apply Assess the fingers of the right hand. Administer tetanus toxoid as ordered by provider. Stabilize the arm at the wrist and elbow. Cover the wound with a clean dressing. Obtain an x-ray of the affected extremity incorrect You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Incorrect (0/1.25 points) 56.0 M8E_N213 1.25/1.25 points (graded) Which client data should the RN assess to determine if baclofen is effective for the client with multiple sclerosis? Serum creatinine Blood pressure Muscle spasticity correct Urine culture You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 57.0 M8E_N213 1.25/1.25 points (graded) An RN receives verbal hand off report on the following clients. Which client should the RN assess first? A client admitted with a CVA who has left sided hemiparesis, stable vital signs, and scheduled for physical therapy in at 10:00 a.m. A client with Huntington’s disease who has twisting movement of their upper extremities and scheduled for discharge to a long-term care facilitylater today. A client with Amyotrophic Lateral Sclerosis whose vital signs are BP 90/60, Respiratory Rate 36, and Oxygen saturation 88%. correct A client admitted with Myasthenia Gravis scheduled for their first plasmapheresis treatment and reports symptoms of diplopia. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 58.0 M8E_N213 1.25/1.25 points (graded) The RN is caring for a client diagnosed with myasthenia gravis. The client has a sudden onset of eyelid ptosis, diplopia, dysarthria, dysphagia and prominent muscle weakness. Which intervention should the RN do first? Provide ventilatory assistance. correct Initiate chest physiotherapy. Administer Tensilon. 1.25/1.25 points (graded) A client with a diagnosis of a fractured hip in Buck’s traction is reporting severe pain. Which intervention should the RN implement first? Adjust the client-controlled analgesia (PCA) machine for an increased dose. Elevate the head of the bead to 45 degrees and the foot to 15 degrees. Ensure that the weights of the Buck’s traction are off the floor and hang free. correct Turn the client on the affected leg using pillows to support the other leg. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 65.0 M8E_N213 1.25/1.25 points (graded) Why does the RN clarify an order for 25 mg cardidopa / 250 mg levodopa intravenously twice a day for an adult client? The medication is given twice a day. The client states this is a new medication. The medication is administered orally. correct The medication dosage is too high. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 66.0 M8E_N213 1.25/1.25 points (graded) Which observation indicates to the RN that the client diagnosed with a fractured wrist is performing range of motion exercises correctly? The client can freely wiggle the fingers of both hands. The exercises are performed with the wrist out of the sling. The client reports less edema in the hand. The exercises are performed with the hand at the level of the heart. correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 67.0 M8E_N213 0/1.25 points (graded) The RN is caring for a client who has sustained an open fracture of the arm. Which interventions should the RN implement? Select all that apply. Wrap the arm in an Ace bandage. Ask the client if able to move the affected arm. Splint or immobilize the injured limb. Cover open area with a clean dressing. Start antibiotics to prevent infection incorrect You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Incorrect (0/1.25 points) 68.0 M8E_N213 1.25/1.25 points (graded) The client reports taking two (2) 650 mg tablets of acetaminophen every 8 hours every day. How many mg of acetaminophen is the client taking daily? Record your answer as a number using decimals if necessary (for example write 0.5 instead of ½). Do not include words or abbreviations in your answer. [x] mg correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 69.0 M8E_N213 3900 1.25/1.25 points (graded) The RN is caring for a client in traction. Which evidenced-based guidelines should the RN implement? Select all that apply. Counter-traction must be used to achieve effective results. Skeletal traction is interrupted to pull the client up in bed. Ropes must be unobstructed and untangled. Traction must be interrupted for the client to be up in the chair Weights must hang freely and not rest on the bed or the floor. correct You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 70.0 M8E_N213 1.25/1.25 points (graded) The RN is caring for a child awaiting surgery to correct a slipped capital femoral epiphysis (SFCE). Which outcome should the RN identify? Reduce potential for infection. Prevent further slippage. correct Stabilize pending radiographic confirmation. Ambulate safely with crutches. You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 71.0 M8E_N213 1.25/1.25 points (graded) The RN is caring for a client who underwent a total knee arthroplasty. Which nursing intervention is the priority to prevent Ineffective tissue perfusion? Educate the client about self-care. Establish a rehabilitation program to meet the client’s needs. Educate the client to perform ankle exercises. correct Client’s serum glucose is 89 mg/dL Client age is 69 years old You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 77.0 M8E_N213 1.25/1.25 points (graded) A client presents to the Emergency Department with an altered level of consciousness (LOC), and is mildly combative after suffering a subarachnoid hemorrhage. The client’s LOC progresses to unconsciousness. When the client begins to emerge from the unconscious state, which intervention would the RN do first? Orient client to time and place correct Maintain hydration status Removal of restraints Assess client temperature You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 78.0 M8E_N213 1.25/1.25 points (graded) The RN is caring for a client who presents with an altered level of consciousness (LOC). The client is able to open their eyes on command. The client has an irregular respiratory pattern, slightly uneven pupils, and facial drooping with drooling on the left side. What is the RN’s first appropriate intervention? Maintain intravenous access Maintain the client’s airway correct Maintain a calm, quiet environment Assess the client’s vital signs You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Correct (1.25/1.25 points) 79.0 M8E_N213 0/1.25 points (graded) The RN responds to a client who is post-operative day two after having an above knee amputation. The client’s surgical elastic dressing has come off. What intervention should the RN do first? Investigate how the dressing came off Immediately apply an elastic compression bandage Assess the client’s surgical site incorrect Notify the surgeon You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Incorrect (0/1.25 points) 80.0 M8E_N213 0/1.25 points (graded) A client admitted to the emergency department with complaint of headache states to the RN “I am late filling my prescription for topiramatebecause I can’t afford it until payday”. Which possible client outcome should the RN be most concerned of the client developing? Nausea and vomiting Status epilepticus Worsening headache from medication withdrawal incorrect Dizziness and fatigue You have used 1 of 1 attempt Some problems have options such as save, reset, hints, or show answer. These options follow the Submit button. Incorrect (0/1.25 points) American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: Nursebooks.org