NUR 2243FINAL EXAM REVIEW; QUESTIONS
WITH DETAILED VERIFIED ANSWERS
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
d. Gains 2 pounds after 1 week - correct answer- 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 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. -
correct answer- 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 client has a small-bore feeding tube (Dobhoff tube) inserted
for continuous enteral feedings while recovering from a
traumatic brain injury. What actions should the nurse include in
the clients care? (Select all that apply.)
a. Assess tube placement per agency policy.
b. Keep the head of the bed elevated at least 30 degrees.
c. Listen to lung sounds at least every 4 hours.
d. Run continuous feedings on a feeding pump.
e. Use blue dye to determine proper placement. - correct
answer- ANS: A, B, C, D
All of these options are important for client safety when
continuous enteral feedings are in use. Blue dye is not used
because it can cause lung injury if aspirated.
A client has a traumatic brain injury and a positive halo sign. The
client is in the intensive care unit, sedated and on a ventilator,
,and is in critical but stable condition. What collaborative
problem takes priority at this time?
a. Inability to communicate
b. Nutritional deficit
c. Risk for acquiring an infection
d. Risk for skin breakdown - correct answer- ANS: C
The positive halo sign indicates a leak of cerebrospinal fluid. This
places the client at high risk of acquiring an infection.
Communication and nutrition are not priorities compared with
preventing a brain infection. The client has a definite risk for a
skin breakdown, but it is not the immediate danger a brain
infection would be.
A client has a traumatic brain injury. The nurse assesses the
following: pulse change from 82 to 60 beats/min, pulse pressure
increase from 26 to 40 mm Hg, and respiratory irregularities.
What action by the nurse takes priority?
a. Call the provider or Rapid Response Team.
b. Increase the rate of the IV fluid administration.
c. Notify respiratory therapy for a breathing treatment.
d. Prepare to give IV pain medication. - correct answer-
ANS: A
, These manifestations indicate Cushings syndrome, a potentially
life-threatening increase in intracranial pressure (ICP), which is
an emergency. Immediate medical attention is necessary, so the
nurse notifies the provider or the Rapid Response Team.
Increasing fluids would increase the ICP. The client does not
need a breathing treatment or pain medication.
A client in the emergency department is having a stroke and
needs a carotid artery angioplasty with stenting. The clients
mental status is deteriorating. What action by the nurse is most
appropriate?
a. Attempt to find the family to sign a consent.
b. Inform the provider that the procedure cannot occur.
c. Nothing; no consent is needed in an emergency.
d. Sign the consent form for the client. - correct answer-
ANS: A
The nurse should attempt to find the family to give consent. If
no family is present or can be found, under the principle of
emergency consent, a life-saving procedure can be performed
without formal consent. The nurse should not just sign the
consent form.
WITH DETAILED VERIFIED ANSWERS
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
d. Gains 2 pounds after 1 week - correct answer- 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 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. -
correct answer- 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 client has a small-bore feeding tube (Dobhoff tube) inserted
for continuous enteral feedings while recovering from a
traumatic brain injury. What actions should the nurse include in
the clients care? (Select all that apply.)
a. Assess tube placement per agency policy.
b. Keep the head of the bed elevated at least 30 degrees.
c. Listen to lung sounds at least every 4 hours.
d. Run continuous feedings on a feeding pump.
e. Use blue dye to determine proper placement. - correct
answer- ANS: A, B, C, D
All of these options are important for client safety when
continuous enteral feedings are in use. Blue dye is not used
because it can cause lung injury if aspirated.
A client has a traumatic brain injury and a positive halo sign. The
client is in the intensive care unit, sedated and on a ventilator,
,and is in critical but stable condition. What collaborative
problem takes priority at this time?
a. Inability to communicate
b. Nutritional deficit
c. Risk for acquiring an infection
d. Risk for skin breakdown - correct answer- ANS: C
The positive halo sign indicates a leak of cerebrospinal fluid. This
places the client at high risk of acquiring an infection.
Communication and nutrition are not priorities compared with
preventing a brain infection. The client has a definite risk for a
skin breakdown, but it is not the immediate danger a brain
infection would be.
A client has a traumatic brain injury. The nurse assesses the
following: pulse change from 82 to 60 beats/min, pulse pressure
increase from 26 to 40 mm Hg, and respiratory irregularities.
What action by the nurse takes priority?
a. Call the provider or Rapid Response Team.
b. Increase the rate of the IV fluid administration.
c. Notify respiratory therapy for a breathing treatment.
d. Prepare to give IV pain medication. - correct answer-
ANS: A
, These manifestations indicate Cushings syndrome, a potentially
life-threatening increase in intracranial pressure (ICP), which is
an emergency. Immediate medical attention is necessary, so the
nurse notifies the provider or the Rapid Response Team.
Increasing fluids would increase the ICP. The client does not
need a breathing treatment or pain medication.
A client in the emergency department is having a stroke and
needs a carotid artery angioplasty with stenting. The clients
mental status is deteriorating. What action by the nurse is most
appropriate?
a. Attempt to find the family to sign a consent.
b. Inform the provider that the procedure cannot occur.
c. Nothing; no consent is needed in an emergency.
d. Sign the consent form for the client. - correct answer-
ANS: A
The nurse should attempt to find the family to give consent. If
no family is present or can be found, under the principle of
emergency consent, a life-saving procedure can be performed
without formal consent. The nurse should not just sign the
consent form.
