Rasmussen College: NU278/NUR2/1PN 3 FINAL STUDY GUIDE EXAM 4_LATEST UPDATED,100% CORRECT

Rasmussen College: NU278/NUR2/1PN 3 FINAL STUDY GUIDE EXAM 4_LATEST UPDATED NUR2790 STUDY GUIDE EXAM 4 Neuro 1. For the client who is at risk for stroke, the most important guideline the nurse should teach is to: A. monitor weight and activity. B. increase drinks with caffeine. C. increase amounts of sodium in the diet. D. monitor blood pressure. 2. A client is being evaluated for a stroke. The nurse knows that one of the easiest and most common diagnostic tests used to differentiate between strokes is: A. magnetic resonance imaging (MRI). B. positron emission tomography (PET). C. electrocardiography (EEG). D. computed tomography (CT). 3. While instructing a client on stroke prevention, the nurse mentions medications that are useful in stroke prevention. The following medications are effective in preventing a stroke, EXCEPT: A. anticholinergics. B. antiplatelets. C. anticoagulants. D. neuroprotective agents. 4. A client is being seen in the emergency department experiencing symptoms of a stroke. The nurse realizes that the administration of a medication to break clots, such as tPA, should be administered within how many minutes of the client presenting to the emergency department? A. 120 minutes B. 90 minutes C. 30 minutes D. 60 minutes 5. What is the major cause of traumatic brain injuries? MVC 6. A client is diagnosed with a mild brain injury. Which of the following is an example of a mild injury? A. A. Vegetative state B. Coma C. Locked-in syndrome D. Concussion 7. The nurse is planning care for a client diagnosed with increased intracranial pressure after a head injury. Which of the following interventions can be used to reduce increased intracranial pressure? A. Perform range-of-motion exercises every hour. B. Keep the head of the bed in the flat position. C. Administer antibiotics as prescribed. D. Administer corticosteroids and osmotic diuretics as prescribed. 8. The nurse, caring for a client recovering from a traumatic brain injury, knows the client and the family are eligible for specific federal programs because of the: A. Associated Brain Act. B. Traumatic Brain Injury Act of 2008. C. Brain Protection Act. D. Health Brain Act. 9. Which of the following should be avoided when caring for a client diagnosed with increased intracranial pressure? A. Placing the client on bed rest B. Placing the bed in Trendelenburg C. Starting an intravenous access line D. Administering oxygen 10. A client is being instructed on treatments available for a newly diagnosed brain tumor. The nurse realizes that this client's treatment could include all of the following EXCEPT: A. photo DNA therapy. B. radiation. C. surgery. D. chemotherapy. 11. A client diagnosed with an embolic stroke is not a candidate for tPA. The nurse realizes that the client might be eligible for which of the following forms of treatment? A. Intravenous fluid therapy B. Carotid endarterectomy C. Carotid stenting D. Antiarrhythmic medication 12. The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? A. Clustering many nursing activities B. Aligning the neck with the body C. Elevating the head of the bed 30 degrees D. Providing stool softeners or laxatives as ordered 13. The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be? A, inability to focus visually B. loss of primitive reflexes. C. unequal pupil size. D. change in level of consciousness. 14. Components of the GCS the nurse would use to assess a patient after a head injury include: A. head circumference. B. verbal responsiveness. C. cranial nerve function. Liver D. Blood pressure 15. A child care worker complains of flu-like symptoms. On further assessment, hepatitis is suspected. The nurse realizes that this individual is at risk for which type of hepatitis? A. Hepatitis A B. Hepatitis D C. Hepatitis C D. Hepatitis B 16. An older male is diagnosed with cirrhosis of the liver. The nurse knows that the most likely cause of this problem is: A. drinking excessive alcohol. B. eating bad food. C. traveling to a foreign country. D. being in the military. 17. A client is scheduled for a liver biopsy. The nurse realizes that the most important sign to assess for is: A. Bleeding. B. Nausea and vomiting. C. infection. D. Pain. 18. The nurse realizes that the organ which is a major site for metastases, harboring and growing cancerous cells that originated in some other part of the body, is the: A. gallbladder B. spleen. D. stomach. 19. A school age child is placed on a waiting list for a liver transplant. The nurse knows that the most common reason for children to need this type of transplant is because of: A. cirrhosis due to hepatitis C B. diabetes. C. Crohn's disease. D. biliary atresia. 20. Because health care workers are at a greater risk of hepatitis B infection, it is recommended that all health care workers: A. drink bottled water only. B. become vaccinated. C. wash their hands often. D. avoid foreign travel. 21. A client who usually smokes a pack of cigarettes a day tells the nurse that he cannot stand the smell of smoke. The nurse realizes that this client is in which phase of hepatitis? A. Recovery B. Icteric C. Preicteric D. Posticteric 22. A female client is surprised to learn that she has been diagnosed with hemochromatosis. Which of the following should the nurse respond to this client? A. "I would ask the doctor if he's sure about the diagnosis." B. "All women have the disorder but not the symptoms." C. "Females often do not experience the effects of the disease until menopause." D. "It doesn't affect people until they are in their 50s." 24. A client is diagnosed with liver disease. Which of the following is one impact of this disorder on a client's fluid and electrolyte status? A. Hyponatremia B. Hypernatremia C. Hypercalcemia D. Hyperkalemia 25. The nurse, caring for a client recovering from the placement of a shunt to treat portal hypertension, should assess the client for which of the following complications associated with this surgery? A. Pulmonary edema B. Pulmonary emboli C. Myocardial infarction D. Decreased peripheral pulses 26. A client is diagnosed with macrovesicular fatty liver. Which of the following should the nurse instruct this client? A. Increase exercise. B. Avoid all alcohol. C. Expect to develop jaundice. D. Treatment includes antibiotic therapy. 27. A client is demonstrating yellow pigmentation of the skin and sclera. Which of the following can be used to describe this client's symptoms? (Select all that apply.) A. Icterus B. Cirrhosis C. Dyspepsia D. Sclerosis E. Jaundice F. Kernicterus 28. A client is diagnosed with a disorder of the liver. The nurse realizes this client might experience which of the following? (Select all that apply.) A. Elevated levels of vitamin E B. Poor digestion of fats C. Increased bleeding D. Insulin resistance E. Nerve damage F. Low vitamin A levels 29. A client is diagnosed with portal hypertension. The nurse should assess the client for which of the following disorders associated with this diagnosis? (Select all that apply.) A. Esophageal varices B. Splenomegaly C. Caput medusae D. Hemorrhoids E. Gastritis F. Gallstone formation Musculoskeletal 30. A client tells the nurse that he has pain, swelling, fatigue, and numbness of his hands. The nurse should assess the client for which of the following occupations? A. Retail store clerk B. Bus driver C. Lifeguard D. Computer keyboard operator 31, A client who plays baseball on the weekends is experiencing an arm injury. The nurse realizes this client needs to be evaluated for: A. lateral epicondylitis. B. a rotator cuff tear. C. dislocation of the shoulder. D. patellar tendinopathy. 32. A client, diagnosed with an ankle sprain, is prescribed ibuprofen to control pain and inflammation. What instruction should the client receive concerning this medication? A. "Take on an empty stomach to maximize its effect." B. "Take with food to minimize gastrointestinal irritation." C. "Wear sunscreen if outside to prevent a burn." D. “Bleeding is not a problem with this medication." 33. A client, experiencing a fractured arm, asks the nurse why the splint is being applied. Which of the following should the nurse respond to this client? A. "It immobilizes the muscles and joints." B. "It prevents the need for surgery." C. "It reduces the need for a cast." D. "It reduces bleeding, swelling and pain." 1. A client has had a cast applied to immobilize a right ulnar fracture. Which of the following nursing interventions is most important? A. Giving pain medication B. Starting discharge teaching C. Checking capillary refill time D. Calling physical therapy for a sling 35. A client with a right arm cast is experiencing signs of a serious complication. Which of the following would cause the nurse the most concern? A. Severe pain to the right arm continues after receiving pain medication B. Itching under the cast C. Finger movement D. Capillary refill time less than 3 seconds 36. A client has been wearing a splint for carpal tunnel syndrome for 7 weeks. The nurse realizes that which of the following would be the next course of treatment for this client? A. Corticosteroid injection B. Casting C. Exercises D. Surgery 37. The nurse is planning care for a client recovering from a meniscal injury. Which of the following should be included as strategies to avoid future injuries? A. Avoid skiing. B. Wear similar shoes for all activities. C. Avoid hamstring muscle exercises. D. Stretch before and after exercise. 38. A client with an ankle sprain is instructed to follow RICE. Which of the following should the nurse instruct the client regarding this process? A. "Apply an elastic bandage to the site." B. "Apply ice to the ankle once a day." C. "Maintain your normal level of activity." D. "Elevate the extremity every day for 20 to 30 minutes." 39. The nurse is instructing a client on ways to prevent the onset of stress fractures. Which of the following should be included in these instructions? A. Increase intensity of training 10% each day B. Avoid overtraining C. Limit warm up exercises D. Avoid shock absorbing footwear 40. The nurse suspects a client, recovering from hip replacement surgery, is experiencing an infection when which of the following is assessed? A. Pain with movement B. Foot intact to sensation and motion C. Blood pressure 110/68 mmHg D. Client using crutches to ambulate 41. The nurse is concerned that a client is demonstrating signs of compartment syndrome. Which of the following is considered a classical symptom of this disorder? (Select all that apply.) A. Paraplegia B. Pain C. Pulselessness D. Pressure E. Paresthesia F. Pink 42. Disease processes that predispose pts to pathological fractures- A client with osteoporosis suffers a fracture, then falls. This type of fracture is called: Selected Answer: Pathological fracture Answers: Pathological fracture Greenstick fracture Comminuted fracture Impacted fracture 43. Pt with #pelvis, dyspnea, and restlessness- what are S/S fat emboli: Sz, upper body petechiae, temp A client, recovering from a fractured pelvis, begins to have dyspnea and restlessness. The nurse is concerned that the client is experiencing a fat emboli when which of the following are assessed? SATA Upper body petechia Seizures Temp 102 MISCELLANEOUS 44. The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? A. Oxygen via face mask at 8 L/min B. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr C. Furosemide (Lasix) 20 mg PO now D. KCl 20 mEq PO two times per day 45. At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? A. Tumor that secretes excessive antidiuretic hormone (ADH) B. Tumor that destroyed the posterior pituitary gland C. Tumor that secretes excessive aldosterone D. Vomiting all day and not replacing any fluid 46. The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? A. Increased skin tenting and dry mouth B. Decreased level of consciousness C. Postural hypotension and tachycardia D. Development of ankle or sacral edema 47. Nursing interventions for hypoK: fall precautions due to potential postural hypotension and weak l leg muscles. The client’s laboratory report today indicates severe hypokalemia and the nurse has notified the practitioner. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? Institute fall precautions due to potential postural hypotension and weak leg muscles 48. The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse's teaching about the acid-base imbalance has been effective? A. "My blood became too acid because I lost some base in the diarrhea fluid." B. "I should try to slow my breathing so my acids and bases will be balanced." C. "To prevent another problem, I should eat less sodium during diarrhea." D. "Diarrhea removes fluid from the body, so I should drink more ice water." 49. The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see? A. pH low, PaCO2 high, HCO3- high B. pH low, PaCO2 high, HCO3- normal C. pH low, PaCO2 low, HCO3- low D. pH high, PaCO2 high, HCO3- high 50. The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first? A. "Is there a place that I can dispose of my unused morphine pills?" B. "I ran out of money and am cutting my insulin dose in half." C. "I want to lose at least 20 pounds without getting sick this time." D. "I think I have asthma because I cough when dogs are near." 51. The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer? A. Colonoscopy at age 50 and every 10 years as follow-up B. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over C. Yearly mammography for women aged 40 years and older D. Using skin protection during sun exposure while at the beach 52. While collecting a health history on a patient admitted for colon cancer, which of the following questions would be a priority to ask this patient? A. "Have you noticed any blood in your stool?" B. "Have you been experiencing nausea?" C. "Do you have back pain?" D. "Have you noticed any swelling in your abdomen?" 53. While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? A. Limiting visitors, thus promoting the maximal amount of hours for sleep B. Completing all nursing care in the morning so the patient can rest the remainder of the day C. Completing all nursing care in the evening when the patient is more rested D. Prioritization and administration of nursing care throughout the day 54. The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life- threatening situation? A. Depression B. Mild temperature elevation (or low grade fever) C. Mucositis D. Confusion 55. While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? A. Cigarette smoking as a teenager B. Being a 75-year-old woman C. Advancing age D. Family history of hypertension (Note: I’m sure about this question and how it will be asked. On the study guide (Misc. #13), she has D, B, and C.) 56. In caring for a patient following lobectomy for lung cancer, which of the following should the nurse include in the plan of care? A. Position the patient on the operative side only. B. Instruct the patient to cough and deep breathe. C. Avoid administering narcotic pain medications. D. Keep the patient on strict bed rest. 57. The patient asks the nurse to explain the sinoatrial node in the heart. The nurse's best response would be, "The sinoatrial node A. protects the heart from infection." B. provides the heart with oxygenated blood." C. provides the heart with the stimulation to beat in a normal rhythm." D. protects the heart from atherosclerotic changes." 58. A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low. The nurse knows that the patient should be observed for A. tissue ischemia. B. intestinal blockage. C. cardiac dysrhythmia. D. brain malformations. 59. A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student states, "Perfusion A. varies as a person ages, so I would expect changes in the body." B. is a normal function of the body, and I don't have to be concerned about it." C. is monitored by vital signs and capillary refill." D. is monitored by the physician, and I just follow orders." 60. The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A. with a heart rate of 100 beats/min and blood pressure of 100/60 B. with a blood glucose of 350 mg/dL C. with a hemoglobin of 8.5 g/dL D. who has been on anticoagulants for 10 days 61. A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? A. The infant is unable to maintain an adequate iron intake. B. There is an increase in intake of breast milk or formula. C. The infant is becoming more active. D. A depletion of fetal hemoglobin occurs. 62. Which statement by a patient indicates additional teaching is required about the medication warfarin? A. "I will continue my diabetic diet and restrict sugar." B. "I will restrict the intake of foods high in vitamin C." C. "I will increase the intake of green, leafy vegetables for a more healthful diet." D. "I will increase the amount of protein in my diet to protect my kidneys." 63. The nurse would expect to administer an anticoagulant to a patient following which surgery? A. Appendectomy B. Hip replacement C. Abdominal aorta aneurism (AAA) repair D. Hysterectomy 64. A patient on a medical surgical unit has a platelet count of 90,000 per mm3. The nurse knows to include which of the following precautions in discharge instructions? A. Have aggressive dental care immediately to prevent dental caries. B. Use a soft bristle toothbrush. C. Do not eat fresh fruit. D. Use a standard safety razor for shaving. 65. The nurse is presenting an in-service on the importance of collaborative communication. The nurse includes which critical event identified by the Joint Commission as an outcome of poor communication among health care team members? A. Decreased ability to document expenses of care provided B. Increased time to discharge patients to outpatient care C. Longer time to begin surgical cases D. The occurrence of a patient event resulting in death or serious injury 66. A client asks the nurse to pray with him. The nurse is an atheist. Which statement by the nurse is the correct response? A. "No, I'm sorry, I can't do that." B. "I'll hold your hand while you pray." C. "No, I don't believe in prayer." D. "Yes, let's pray together." 67. The nurse is being trained in hospice care. Which intervention by the nurse is most compatible with the goals of end-of-life care for the client? A. Perform passive range-of-motion exercises to prevent contractures. B. Permit the client with diabetes mellitus to have a serving of ice cream. C. Prevent the client with chronic obstructive pulmonary disease from smoking. D. Administer influenza and pneumococcal vaccinations. 68. Which statement best exemplifies a client's understanding of rehabilitation after a full-thickness burn injury? A. "I will eventually be able to perform all my former activities." B. "My goal is to achieve the highest level of functioning that I can." C. "I am fully recovered when all the wounds are closed." D. "Full recovery from a major burn injury never occurs." 69. A client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse's best response? A. "This will help prevent stomach ulcers, which are common after burns." B. "Tagamet can help prevent hypovolemic shock, which can be fatal." C. "This drug will help prevent kidney damage caused by dehydration." D. "Tagamet will stimulate intestinal movement so you can eat more." 70. A client who is burned is drooling and is having difficulty swallowing. Which action does the nurse take first? A. Measure abdominal girth and auscultate bowel sounds. B. Assess level of consciousness and pupillary reactions. C. Auscultate breath sounds over the trachea and mainstem bronchi. D. Ascertain the time food or liquid was last consumed. 71. The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse? A. Encourage the client to take deep, controlled breaths. B. Stabilize the chest wall with rib binders. C. Document findings and continue to monitor the client. D. Notify the health care provider and prepare for intubation. 72. What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation? A. Ask the client to blink for "yes" and "no." B. Teach the client some simple sign language. C. Have the client mouth words slowly. D. Ask the client to point to words on a board. 73. A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer? A. Metoprolol (Lopressor) B. Lidocaine (Xylocaine) C. Atropine (Atropine) D. Digoxin (Lanoxin) 74. A client's electrocardiograph (ECG) tracing shows a run of sustained ventricular tachycardia. What is the nurse's first action? A. Cardiovert the client with a biphasic defibrillator. B. Administer an amiodarone bolus followed by a drip. C. Begin cardiopulmonary resuscitation (CPR). D. Assess airway, breathing, and level of consciousness. 75. A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement. Which fluid does the nurse prepare to administer? A. 5% dextrose in water B. Ringer's lactate C. Normal saline D. 5% dextrose in 0.45% normal saline 76. A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first? A. Obtain two sets of blood cultures. B. Administer the prescribed IV vancomycin (Vancocin). C. Administer the prescribed IV norepinephrine (Levophed). D. Obtain central venous pressure (CVP) measurements. 77. The nurse is caring for a client who had a myocardial infarction. The client develops increased pulmonary congestion; an increase in heart rate from 80 to 102 beats/min; and cold, clammy skin. Which action does the nurse implement before notifying the health care provider? A. Increase the IV flow rate. B. Prepare the client for surgery. C. Place the client in supine position. D. Administer oxygen. 78. A client has received vasopressin (DDAVP) for diabetes insipidus. Which assessment finding indicates a therapeutic response to this therapy? A. Urine output is decreased; specific gravity is increased. B. Urine output is increased; specific gravity is decreased. C. Urine output is increased; specific gravity is increased. D. Urine output is decreased; specific gravity is decreased. 79. Which client is most at risk for developing postrenal kidney failure? A. Client with congestive heart failure B. Client taking NSAIDs for arthritis pain C. Client recovering from glomerulonephritis D. Client diagnosed with renal calculi 80. The nurse, planning care for a client recovering from a traumatic brain injury, is including interventions to prevent sympathetic storming. Which of the following should be included in this client's plan of care? (Select all that apply.) A. Elevated blood pressure indicates a sympathetic storm is ending. B. Provide beta-blockers as prescribed with symptoms of sympathetic storm. C. Medicate for pain prior to conducting a painful procedure. D. If symptoms of sympathetic storm do not appear within 24 hours, the client will not develop this health problem. E. Cardiac arrhythmias indicate a drop in intracranial pressure. F. Continue suctioning until the client's heart rate is greater than 100 beats per minute. (Note: This is a question she told us to “add in.” She only mentioned “blood pressure 190/120.” Verify other answers found.) 81. A client, being tested for a stroke, is not a candidate for tPA. Which of the following would be contraindicated for the use of tPA? (Select all that apply.) A. Blood pressure 190/120 mmHg B. Minor ischemic stroke within 30 days C. Glucose level 120 mg/dL D. Lumbar puncture 2 days ago E. Stroke onset 5 hours ago F. INR 1.0 82. A client is being instructed on treatments available for a newly diagnosed brain tumor. The nurse realizes that this client's treatment could include all of the following EXCEPT: A. photo DNA therapy. B. radiation. C. surgery. D. chemotherapy. 83. A client diagnosed with cirrhosis is experiencing the complication of ascites. Which of the following would be considered treatment for this complication? (Select all that apply.) A. Pain medication B. Diuretic therapy C. Low-sodium diet D. Bed rest E. Fluid restriction F. Increased exercise 84. Most common complication of Endoscopic Retrograde cholangiopancreatography (ERCP)? Bleeding Perforation of stomach and duodenum, pancreatitis, aspirate gastric content, anaphylactic reaction to contrast dye (**cannot perforate bladder**) 85. S/S of dvt post abdominal sx? Pain, redness, chest pain, dyspnea, hemoptysis 86. The nurse is planning care for a client recovering from an amputation. Which of the following should be included in this plan of care? (Select all that apply.) A. Provide pain medication 30 minutes before stump care. B. Elevate the stump on a pillow. C. Wash the stump daily with mild soap and warm water. D. Allow the stump to dry open to the air for 10 minutes after . E. E. Lie prone 10 to 20 minutes every day. F. Avoid massaging the stump. 87. A client is anxious about having a dressing change. Which statement indicates that the nurse is promoting appropriate complementary therapy? A. "I'll call the doctor and ask for a larger dose of pain medication before the dressing change." B. "I'll get another nurse to stay in the room with us during the dressing change so that you have a hand to hold during the procedure." C. "As we begin the next dressing change, I want you to think of a beautiful, calm place where you feel happy and peaceful." D. "Are you familiar with acupuncture? It's a very effective technique." 88. The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) A. Endocrine system B. Immune system C. Pulmonary system D. Neurologic system E. Hepatic system F. Cardiovascular system 89. Indication of good ventilation- The nurse is assessing a client for the adequacy of ventilation. What assessment findings would indicate the client has good ventilation? (SATA) Oxygen saturation level is 98% Nail beds are pink with good capillary refill There is presence of quiet, effortless breath sounds at lung base bilaterally