Adult Health lll Exam 4 Answers
Starting on question #3
1. The nurse on the neurological unit is positioning a client who had a stroke two days ago
and had left-sided hemiparesis. Which of the following actions by the nurse would be
appropriate? Select all that apply.
a. Positioning a rolled washcloth in the client’s left hand
b. Placing a foam abduction wedge between the client’s legs
c. Grasping the client’s left arm to pull the client from supine to a right side-lying
position
d. Securing the left arm in a sling
e. Putting a trochanter roll on the outside of the client’s left hip when the client is
supine.
2. The nurse is caring for a client who has expressive aphasia following a stroke. The nurse
has taught the client’s spouse about ways to facilitate communication. Which of the
following comments by the client’s spouse would require follow-up?
a. “I wait after I ask my spouse a question, to give as much time as needed to
answer.”
b. “I ask my spouse questions like, ‘Do you like this movie?’ instead of ‘What do
you think of this movie?’”
c. “I act like I understand when I do not, so that my spouse will not become
frustrated.”
d. “I tell my spouse, ‘Point to what you want” so I do not get frustrated trying to
understand.”
3. The nurse is caring for a client with increased intracranial pressure (ICP) who has
developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the
following prescribed interventions should the nurse implement?
a. Electrolyte restriction
b. Electrolyte replacement
c. Fluid replacement
d. Fluid restriction
4. The nurse is planning care for a client who has a recent diagnosis of multiple sclerosis
(MS). Which of the following interventions should the nurse include in the client’s care
plan?
a. Instruct the client on daily muscle stretching exercises
b. Provide total assistance with all activities of daily living (ADLs)
c. Encourage the client to follow a low-residue diet
d. Encourage client to void every hour
5. The nurse is caring for a group of assigned clients. Which of the following client’s should
the nurse see first?
a. The client with ulcerative colitis who reports left lower quadrant abdominal pain
and passing stools that appear bloody with mucus and pus.
, b. The client with breast cancer receiving prescribed chemotherapy whose platelet
count is 52,000/uL and reports having shaking chills.
c. The client with hepatitis B virus who was admitted with jaundice and now has
changes in cognitive function.
d. The client recovering from an ischemic stroke who has decreased lung sounds,
productive cough and a temperature of 104.8 F.
6. The nurse is planning an education conference about anticoagulation and the direct factor
Xa inhibitor medications. Select all that apply.
a. Aspirin
b. Coumadin
c. Dipyridamole
d. Rivaroxaban
e. Apixaban
7. The nurse in an outpatient setting is assessing a client’s risk for ischemic stroke. The
nurse should assess for which of the following conditions? Select all that apply.
a. Atrial fibrillation
b. Hemophilia
c. Diabetes Mellitus
d. Epilepsy
e. Concussion
f. Carotid Stenosis
8. The nurse is caring for a client with a traumatic brain injury (TBI) following a fall. Which
of the following medications should the nurse anticipate being prescribed for the client to
reduce cerebral edema?
a. Mannitol
b. Spirolactone
c. Furosemide
d. Hydrochlorothiazide
9. The nurse is preparing to administer prescribed dexamethasone 7.5 mg daily in divided
doses every 6 hours to a client with vasogenic edema. The nurse has 10 mg/mL available.
How many mL per dose should the nurse administer? Round your answer to the nearest
tenth place. 0.2
10. The nurse is preparing to prescribe bevacizumab 10 mg/kg, IV, every 14 days for a client
with a glioblastoma. The client weighs 160 lbs. The nurse has available 25 mg/mL. How
many mL per dose should the nurse administer to the client? 29
11. The nurse is admitting a 16-year-old client who returned home early from summer camp
with fever, severe headache, and vomiting. Which of the following prescribed
interventions should the nurse implement first?
a. Prepare the client for lumbar puncture
b. Administer antibiotics and pain medication
Starting on question #3
1. The nurse on the neurological unit is positioning a client who had a stroke two days ago
and had left-sided hemiparesis. Which of the following actions by the nurse would be
appropriate? Select all that apply.
a. Positioning a rolled washcloth in the client’s left hand
b. Placing a foam abduction wedge between the client’s legs
c. Grasping the client’s left arm to pull the client from supine to a right side-lying
position
d. Securing the left arm in a sling
e. Putting a trochanter roll on the outside of the client’s left hip when the client is
supine.
2. The nurse is caring for a client who has expressive aphasia following a stroke. The nurse
has taught the client’s spouse about ways to facilitate communication. Which of the
following comments by the client’s spouse would require follow-up?
a. “I wait after I ask my spouse a question, to give as much time as needed to
answer.”
b. “I ask my spouse questions like, ‘Do you like this movie?’ instead of ‘What do
you think of this movie?’”
c. “I act like I understand when I do not, so that my spouse will not become
frustrated.”
d. “I tell my spouse, ‘Point to what you want” so I do not get frustrated trying to
understand.”
3. The nurse is caring for a client with increased intracranial pressure (ICP) who has
developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the
following prescribed interventions should the nurse implement?
a. Electrolyte restriction
b. Electrolyte replacement
c. Fluid replacement
d. Fluid restriction
4. The nurse is planning care for a client who has a recent diagnosis of multiple sclerosis
(MS). Which of the following interventions should the nurse include in the client’s care
plan?
a. Instruct the client on daily muscle stretching exercises
b. Provide total assistance with all activities of daily living (ADLs)
c. Encourage the client to follow a low-residue diet
d. Encourage client to void every hour
5. The nurse is caring for a group of assigned clients. Which of the following client’s should
the nurse see first?
a. The client with ulcerative colitis who reports left lower quadrant abdominal pain
and passing stools that appear bloody with mucus and pus.
, b. The client with breast cancer receiving prescribed chemotherapy whose platelet
count is 52,000/uL and reports having shaking chills.
c. The client with hepatitis B virus who was admitted with jaundice and now has
changes in cognitive function.
d. The client recovering from an ischemic stroke who has decreased lung sounds,
productive cough and a temperature of 104.8 F.
6. The nurse is planning an education conference about anticoagulation and the direct factor
Xa inhibitor medications. Select all that apply.
a. Aspirin
b. Coumadin
c. Dipyridamole
d. Rivaroxaban
e. Apixaban
7. The nurse in an outpatient setting is assessing a client’s risk for ischemic stroke. The
nurse should assess for which of the following conditions? Select all that apply.
a. Atrial fibrillation
b. Hemophilia
c. Diabetes Mellitus
d. Epilepsy
e. Concussion
f. Carotid Stenosis
8. The nurse is caring for a client with a traumatic brain injury (TBI) following a fall. Which
of the following medications should the nurse anticipate being prescribed for the client to
reduce cerebral edema?
a. Mannitol
b. Spirolactone
c. Furosemide
d. Hydrochlorothiazide
9. The nurse is preparing to administer prescribed dexamethasone 7.5 mg daily in divided
doses every 6 hours to a client with vasogenic edema. The nurse has 10 mg/mL available.
How many mL per dose should the nurse administer? Round your answer to the nearest
tenth place. 0.2
10. The nurse is preparing to prescribe bevacizumab 10 mg/kg, IV, every 14 days for a client
with a glioblastoma. The client weighs 160 lbs. The nurse has available 25 mg/mL. How
many mL per dose should the nurse administer to the client? 29
11. The nurse is admitting a 16-year-old client who returned home early from summer camp
with fever, severe headache, and vomiting. Which of the following prescribed
interventions should the nurse implement first?
a. Prepare the client for lumbar puncture
b. Administer antibiotics and pain medication
