Exam (Questions with Answers)
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,1. Questions
A client reports for a scheduled electroencephalogram
(EEG). Which statement by the client indicates a need for
additional preparation for the test?
A. “I didn’t shampoo my hair.” Correct
B. “I ate breakfast this morning.”
C. “I didn’t take my anticonvulsant today.”
D. “It was hard not to drink coffee this morning, but
I knew thatcare
Rationale: Preprocedure I couldn’t, so I didn’t.”
for EEG involves client teaching about the
procedure, ensuring that the client’s hair has been freshly shampooed, and
providing a light meal and fluids to prevent hypoglycemia, which could alter
HESI Concepts:
brain waves. Teaching such
Medications and Learning/Patient
as antidepressants,Education, Intracranial
tranquilizers, and
Regulation
anticonvulsants are withheld for 24 to 48 hours before the procedure as
prescribed. Ignatavicius,
Reference: Stimulants suchD., &
asWorkman,
coffee, tea,
M.cola,
(2013).
alcohol, and cigarettes
Medical-surgical are
nursing:
Patient-centered
also withheld. collaborative care. (7 ed., pp. 922-923). St. Louis: Saunders.
th
Test-Taking Strategy: Use your knowledge of the EEG procedure to answer the
Awarded
question and1.0
notepoints out words
the strategic of 1.0“needs
possible points.
additional preparation.” These
words indicate a negative event query and the need to select the incorrect
client statement. Recalling the purpose of an EEG and the anatomical location
of this test will direct you to the correct option. Review preparation for an EEG
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Fundamentals of Care: Diagnostic Tests and Procedures
Giddens Concepts: Client Education, Intracranial Regulation
,2. 2.ID: 9477054249
A client who just returned from the recovery room after
a tonsillectomy and adenoidectomy is restless and the
pulse rate is increased. As the nurse continues the
assessment, the client begins to vomit a copious
amount of bright-red blood. The nurse should take
which immediate action?
A. Notify the surgeon Correct
B. Continue the assessment
, C. Check the client’s blood pressure
D. Obtain a flashlight, gauze, and a curved
hemostat
Rationale: Hemorrhage is a potential complication after tonsillectomy and
adenoidectomy. If the client vomits a large amount of bright-red blood or the
pulse rate increases and the patient is restless, the nurse must notify the
surgeon immediately. The nurse should obtain a light, mirror, gauze, curved
hemostat, and waste basin to facilitate examination of the surgical site. The
nurse should also gather additional assessment data, but the surgeon must be
contacted immediately.
Test-Taking Strategy: Note the strategic word, immediate. Noting the words
“bright-red blood” will assist in directing you to the correct option. Remember
that the presence of bright-red blood indicates active bleeding. Review the
nursing actions to be taken immediately when bleeding occurs after a
tonsillectomy and adenoidectomy
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care: Emergency Situation/Management
Giddens Concepts: Collaboration, Clotting
HESI Concepts: Collaboration/Managing Care, Perfusion-Clotting
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p. 644). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9477051455
A client who has just undergone surgery suddenly