2
NUR-211 Test 2 with verified detailed answers || || || || || ||
A client is in the emergency department reporting a brief episode during which he was
|| || || || || || || || || || || || || || ||
dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's
|| || || || || || || || || || || || || || ||
neurologic examination is normal. About what drug should the nurse plan to teach the
|| || || || || || || || || || || || || ||
client?
a. Alteplase (Activase)
|| ||
b. Clopidogrel (Plavix)
|| ||
c. Heparin sodium
|| ||
d. Mannitol (Osmitrol) - ✔✔ANS: B
|| || || || ||
This client's manifestations are consistent with a transient ischemic attack, and the client
|| || || || || || || || || || || || ||
would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic
|| || || || || || || || || || || || ||
stroke. Heparin and mannitol are not used for this condition.
|| || || || || || || || ||
A client had an embolic stroke and is having an echocardiogram. When the client asks why
|| || || || || || || || || || || || || || || ||
the provider ordered "a test on my heart," how should the nurse respond?
|| || || || || || || || || || || ||
a. "Most of these types of blood clots come from the heart."
|| || || || || || || || || || ||
b. "Some of the blood clots may have gone to your heart too."
|| || || || || || || || || || || ||
c. "We need to see if your heart is strong enough for therapy."
|| || || || || || || || || || || ||
d. "Your heart may have been damaged in the stroke too." - ✔✔ANS:A
|| || || || || || || || || || || ||
An embolic stroke is caused when blood clots travel from one area of the body to the brain.
|| || || || || || || || || || || || || || || || || ||
The most common source of the clots is the heart. The other statements are inaccurate.
|| || || || || || || || || || || || || ||
A nurse receives a report on a client who had a left-sided stroke and has homonymous
|| || || || || || || || || || || || || || || ||
hemianopsia. What action by the nurse is most appropriate for this client? || || || || || || || || || || ||
a. Assess for bladder retention and/or incontinence.
|| || || || || ||
b. Listen to the client's lungs after eating or drinking.
|| || || || || || || || ||
,2
c. Prop the client's right side up when sitting in a chair.
|| || || || || || || || || || ||
d. Rotate the client's meal tray when the client stops eating. - ✔✔ANS:D
|| || || || || || || || || || || ||
This condition is blindness on the same side of both eyes. The client must turn his or her
|| || || || || || || || || || || || || || || || || ||
head to see the entire visual field. The client may not see all the food on the tray, so the
|| || || || || || || || || || || || || || || || || || || ||
nurse rotates it so uneaten food is now within the visual field. This condition is not related
|| || || || || || || || || || || || || || || || ||
to bladder function, difficulty swallowing, or lack of trunk control.
|| || || || || || || || ||
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the
|| || || || || || || || || || || || || || ||
client or family is most important for the nurse to obtain?
|| || || || || || || || || ||
a. Loss of bladder control
|| || || ||
b. Other medical conditions
|| || ||
c. Progression of symptoms
|| || ||
d. Time of symptom onset - ✔✔ANS:D
|| || || || || ||
The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact
|| || || || || || || || || || || || || || || || || ||
time of symptom onset is the most important information for this client. The other
|| || || || || || || || || || || || || ||
information is not as critical. || || || ||
A client is being prepared for a mechanical embolectomy. What action by the nurse takes
|| || || || || || || || || || || || || || ||
priority?
a. Assess for contraindications to fibrinolytics.
|| || || || ||
b. Ensure that informed consent is on the chart.
|| || || || || || || ||
c. Perform a full neurologic assessment.
|| || || || ||
d. Review the client's medication lists. - ✔✔ANS:B
|| || || || || || ||
For this invasive procedure, the client needs to give informed consent. The nurse ensures
|| || || || || || || || || || || || || ||
that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A
|| || || || || || || || || || || || || || || ||
neurologic assessment and medication review are important, but the consent is the priority.
|| || || || || || || || || || || ||
A client had an embolectomy for an arteriovenous malformation (AVM). The client is now
|| || || || || || || || || || || || || ||
reporting a severe headache and has vomited. What action by the nurse takes priority?
|| || || || || || || || || || || || ||
,2
a. Administer pain medication.
|| || ||
b. Assess the client's vital signs.
|| || || || ||
c. Notify the Rapid Response Team.
|| || || || ||
d. Raise the head of the bed. - ✔✔ANS:C
|| || || || || || || ||
This client may be experiencing a rebleed from the AVM. The most important action is to
|| || || || || || || || || || || || || || || ||
call the Rapid Response Team as this is an emergency. The nurse can assess vital signs
|| || || || || || || || || || || || || || || ||
while someone else notifies the Team, but getting immediate medical attention is the
|| || || || || || || || || || || || ||
priority. Administering pain medication may not be warranted if the client must return to
|| || || || || || || || || || || || || ||
surgery. The optimal position for the client with an AVM has not been determined, but
|| || || || || || || || || || || || || || ||
calling the Rapid Response Team takes priority over positioning.
|| || || || || || || ||
A student nurse is preparing morning medications for a client who had a stroke. The
|| || || || || || || || || || || || || || ||
student plans to hold the docusate sodium (Colace) because the client had a large stool
|| || || || || || || || || || || || || || ||
earlier. What action by the supervising nurse is best?
|| || || || || || || ||
a. Have the student ask the client if it is desired or not.
|| || || || || || || || || || || ||
b. Inform the student that the docusate should be given.
|| || || || || || || || ||
c. Tell the student to document the rationale.
|| || || || || || ||
d. Tell the student to give it unless the client refuses. - ✔✔ANS:B
|| || || || || || || || || || || ||
Stool softeners should be given to clients with neurologic disorders in order to prevent an
|| || || || || || || || || || || || || || ||
elevation in intracranial pressure that accompanies the Valsalva maneuver when
|| || || || || || || || || ||
constipated. The supervising nurse should instruct the student to administer the docusate. || || || || || || || || || || || ||
The other options are not appropriate. The medication could be held for diarrhea.
|| || || || || || || || || || || ||
A client experiences impaired swallowing after a stroke and has worked with speech-
|| || || || || || || || || || || ||
language pathology on eating. What nursing assessment best indicates that a priority goal
|| || || || || || || || || || || || ||
for this problem has been met?
|| || || || ||
a. Chooses preferred items from the menu
|| || || || || ||
b. Eats 75% to 100% of all meals and snacks
|| || || || || || || || ||
c. Has clear lung sounds on auscultation
|| || || || || ||
, 2
d. Gains 2 pounds after 1 week - ✔✔ANS:C
|| || || || || || || ||
Impaired swallowing can lead to aspiration, so the priority goal for this problem is no
|| || || || || || || || || || || || || || ||
aspiration. Clear lung sounds is the best indicator that aspiration has not occurred.
|| || || || || || || || || || || || ||
Choosing menu items is not related to this problem. Eating meals does not indicate the
|| || || || || || || || || || || || || || ||
client is not still aspirating. A weight gain indicates improved nutrition but still does not
|| || || || || || || || || || || || || || ||
show a lack of aspiration. || || || ||
A client with a stroke has damage to Broca's area. What intervention to promote
|| || || || || || || || || || || || || ||
communication is best for this client? || || || || ||
a. Assess whether or not the client can write.
|| || || || || || || ||
b. Communicate using "yes-or-no" questions.
|| || || ||
c. Reinforce speech therapy exercises.
|| || || ||
d. Remind the client not to use neologisms. - ✔✔ANS: A
|| || || || || || || || || ||
Damage to Broca's area often leads to expressive aphasia, wherein the client can understand
|| || || || || || || || || || || || ||
what is said but cannot express thoughts verbally. In some instances the client can write.
|| || || || || || || || || || || || || || || ||
The nurse should assess to see if that ability is intact. "Yes-or-no" questions are not good for
|| || || || || || || || || || || || || || || || ||
this type of client because he or she will often answer automatically but incorrectly.
|| || || || || || || || || || || || || ||
Reinforcing speech therapy exercises is good for all clients with communication difficulties.
|| || || || || || || || || || || ||
Neologisms are made-up "words" often used by clients with sensory aphasia. || || || || || || || || || ||
A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and
|| || || || || || || || || || || || || || ||
determines the client's score to be 36. How should the nurse plan care for this client?
|| || || || || || || || || || || || || || ||
a. The client will need near-total care.
|| || || || || ||
b. The client will need cuing only.
|| || || || || ||
c. The client will need safety precautions.
|| || || || || ||
d. The client will be discharged home. - ✔✔ANS:A
|| || || || || || || ||
This client has severe neurologic deficits and will need near-total care. Safety precautions
|| || || || || || || || || || || || ||
are important but do not give a full picture of the client's dependence. The client will need
|| || || || || || || || || || || || || || || || ||
more than cuing to complete tasks. A home discharge may be possible, but this does not
|| || || || || || || || || || || || || || || ||
help the nurse plan care for a very dependent client.
|| || || || || || || || ||
NUR-211 Test 2 with verified detailed answers || || || || || ||
A client is in the emergency department reporting a brief episode during which he was
|| || || || || || || || || || || || || || ||
dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's
|| || || || || || || || || || || || || || ||
neurologic examination is normal. About what drug should the nurse plan to teach the
|| || || || || || || || || || || || || ||
client?
a. Alteplase (Activase)
|| ||
b. Clopidogrel (Plavix)
|| ||
c. Heparin sodium
|| ||
d. Mannitol (Osmitrol) - ✔✔ANS: B
|| || || || ||
This client's manifestations are consistent with a transient ischemic attack, and the client
|| || || || || || || || || || || || ||
would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic
|| || || || || || || || || || || || ||
stroke. Heparin and mannitol are not used for this condition.
|| || || || || || || || ||
A client had an embolic stroke and is having an echocardiogram. When the client asks why
|| || || || || || || || || || || || || || || ||
the provider ordered "a test on my heart," how should the nurse respond?
|| || || || || || || || || || || ||
a. "Most of these types of blood clots come from the heart."
|| || || || || || || || || || ||
b. "Some of the blood clots may have gone to your heart too."
|| || || || || || || || || || || ||
c. "We need to see if your heart is strong enough for therapy."
|| || || || || || || || || || || ||
d. "Your heart may have been damaged in the stroke too." - ✔✔ANS:A
|| || || || || || || || || || || ||
An embolic stroke is caused when blood clots travel from one area of the body to the brain.
|| || || || || || || || || || || || || || || || || ||
The most common source of the clots is the heart. The other statements are inaccurate.
|| || || || || || || || || || || || || ||
A nurse receives a report on a client who had a left-sided stroke and has homonymous
|| || || || || || || || || || || || || || || ||
hemianopsia. What action by the nurse is most appropriate for this client? || || || || || || || || || || ||
a. Assess for bladder retention and/or incontinence.
|| || || || || ||
b. Listen to the client's lungs after eating or drinking.
|| || || || || || || || ||
,2
c. Prop the client's right side up when sitting in a chair.
|| || || || || || || || || || ||
d. Rotate the client's meal tray when the client stops eating. - ✔✔ANS:D
|| || || || || || || || || || || ||
This condition is blindness on the same side of both eyes. The client must turn his or her
|| || || || || || || || || || || || || || || || || ||
head to see the entire visual field. The client may not see all the food on the tray, so the
|| || || || || || || || || || || || || || || || || || || ||
nurse rotates it so uneaten food is now within the visual field. This condition is not related
|| || || || || || || || || || || || || || || || ||
to bladder function, difficulty swallowing, or lack of trunk control.
|| || || || || || || || ||
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the
|| || || || || || || || || || || || || || ||
client or family is most important for the nurse to obtain?
|| || || || || || || || || ||
a. Loss of bladder control
|| || || ||
b. Other medical conditions
|| || ||
c. Progression of symptoms
|| || ||
d. Time of symptom onset - ✔✔ANS:D
|| || || || || ||
The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact
|| || || || || || || || || || || || || || || || || ||
time of symptom onset is the most important information for this client. The other
|| || || || || || || || || || || || || ||
information is not as critical. || || || ||
A client is being prepared for a mechanical embolectomy. What action by the nurse takes
|| || || || || || || || || || || || || || ||
priority?
a. Assess for contraindications to fibrinolytics.
|| || || || ||
b. Ensure that informed consent is on the chart.
|| || || || || || || ||
c. Perform a full neurologic assessment.
|| || || || ||
d. Review the client's medication lists. - ✔✔ANS:B
|| || || || || || ||
For this invasive procedure, the client needs to give informed consent. The nurse ensures
|| || || || || || || || || || || || || ||
that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A
|| || || || || || || || || || || || || || || ||
neurologic assessment and medication review are important, but the consent is the priority.
|| || || || || || || || || || || ||
A client had an embolectomy for an arteriovenous malformation (AVM). The client is now
|| || || || || || || || || || || || || ||
reporting a severe headache and has vomited. What action by the nurse takes priority?
|| || || || || || || || || || || || ||
,2
a. Administer pain medication.
|| || ||
b. Assess the client's vital signs.
|| || || || ||
c. Notify the Rapid Response Team.
|| || || || ||
d. Raise the head of the bed. - ✔✔ANS:C
|| || || || || || || ||
This client may be experiencing a rebleed from the AVM. The most important action is to
|| || || || || || || || || || || || || || || ||
call the Rapid Response Team as this is an emergency. The nurse can assess vital signs
|| || || || || || || || || || || || || || || ||
while someone else notifies the Team, but getting immediate medical attention is the
|| || || || || || || || || || || || ||
priority. Administering pain medication may not be warranted if the client must return to
|| || || || || || || || || || || || || ||
surgery. The optimal position for the client with an AVM has not been determined, but
|| || || || || || || || || || || || || || ||
calling the Rapid Response Team takes priority over positioning.
|| || || || || || || ||
A student nurse is preparing morning medications for a client who had a stroke. The
|| || || || || || || || || || || || || || ||
student plans to hold the docusate sodium (Colace) because the client had a large stool
|| || || || || || || || || || || || || || ||
earlier. What action by the supervising nurse is best?
|| || || || || || || ||
a. Have the student ask the client if it is desired or not.
|| || || || || || || || || || || ||
b. Inform the student that the docusate should be given.
|| || || || || || || || ||
c. Tell the student to document the rationale.
|| || || || || || ||
d. Tell the student to give it unless the client refuses. - ✔✔ANS:B
|| || || || || || || || || || || ||
Stool softeners should be given to clients with neurologic disorders in order to prevent an
|| || || || || || || || || || || || || || ||
elevation in intracranial pressure that accompanies the Valsalva maneuver when
|| || || || || || || || || ||
constipated. The supervising nurse should instruct the student to administer the docusate. || || || || || || || || || || || ||
The other options are not appropriate. The medication could be held for diarrhea.
|| || || || || || || || || || || ||
A client experiences impaired swallowing after a stroke and has worked with speech-
|| || || || || || || || || || || ||
language pathology on eating. What nursing assessment best indicates that a priority goal
|| || || || || || || || || || || || ||
for this problem has been met?
|| || || || ||
a. Chooses preferred items from the menu
|| || || || || ||
b. Eats 75% to 100% of all meals and snacks
|| || || || || || || || ||
c. Has clear lung sounds on auscultation
|| || || || || ||
, 2
d. Gains 2 pounds after 1 week - ✔✔ANS:C
|| || || || || || || ||
Impaired swallowing can lead to aspiration, so the priority goal for this problem is no
|| || || || || || || || || || || || || || ||
aspiration. Clear lung sounds is the best indicator that aspiration has not occurred.
|| || || || || || || || || || || || ||
Choosing menu items is not related to this problem. Eating meals does not indicate the
|| || || || || || || || || || || || || || ||
client is not still aspirating. A weight gain indicates improved nutrition but still does not
|| || || || || || || || || || || || || || ||
show a lack of aspiration. || || || ||
A client with a stroke has damage to Broca's area. What intervention to promote
|| || || || || || || || || || || || || ||
communication is best for this client? || || || || ||
a. Assess whether or not the client can write.
|| || || || || || || ||
b. Communicate using "yes-or-no" questions.
|| || || ||
c. Reinforce speech therapy exercises.
|| || || ||
d. Remind the client not to use neologisms. - ✔✔ANS: A
|| || || || || || || || || ||
Damage to Broca's area often leads to expressive aphasia, wherein the client can understand
|| || || || || || || || || || || || ||
what is said but cannot express thoughts verbally. In some instances the client can write.
|| || || || || || || || || || || || || || || ||
The nurse should assess to see if that ability is intact. "Yes-or-no" questions are not good for
|| || || || || || || || || || || || || || || || ||
this type of client because he or she will often answer automatically but incorrectly.
|| || || || || || || || || || || || || ||
Reinforcing speech therapy exercises is good for all clients with communication difficulties.
|| || || || || || || || || || || ||
Neologisms are made-up "words" often used by clients with sensory aphasia. || || || || || || || || || ||
A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and
|| || || || || || || || || || || || || || ||
determines the client's score to be 36. How should the nurse plan care for this client?
|| || || || || || || || || || || || || || ||
a. The client will need near-total care.
|| || || || || ||
b. The client will need cuing only.
|| || || || || ||
c. The client will need safety precautions.
|| || || || || ||
d. The client will be discharged home. - ✔✔ANS:A
|| || || || || || || ||
This client has severe neurologic deficits and will need near-total care. Safety precautions
|| || || || || || || || || || || || ||
are important but do not give a full picture of the client's dependence. The client will need
|| || || || || || || || || || || || || || || || ||
more than cuing to complete tasks. A home discharge may be possible, but this does not
|| || || || || || || || || || || || || || || ||
help the nurse plan care for a very dependent client.
|| || || || || || || || ||
