NURS_4_exam_5_practice_questions

1. The client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. A. Bite block at the bedside B. Intravenous access C. Continuous sedation D. Suction equipment at the bedside E. Siderails up 2. The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? A. Absence B. Myoclonic C. Simple partial D. Tonic Seizures 3. The client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What will the nurse do first? A. Administer phenytoin (Dilantin) B. Draw blood C. Assess the need for additional support D. Start an intravenous (IV) line 4. The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure B. Forces a tongue blade in the mouth C. Restrains the client D. Positions the client on the side 5. The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Select all that apply. A. Alopecia B. Headaches C. Dizziness D. Diplopia 6. The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C) 7. The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been requested for treatment of epilepsy. The nurse plans to instruct the client to avoid which beverage? A. Apple juice B. Grape juice C. Grapefruit juice D. Milk 8. A client with a history of seizures is placed on seizure precautions. What emergency equipment will the nurse provide at the bedside? Select all that apply. A. Padded tongue blade B. Oxygen setup C. Nasogastric tube D. Suction setup E. Artificial oral airway 9. Following a generalized tonic-clonic seizure, the patient is tired and sleepy. The nurse should: a) suction the patient before allowing him to rest b) allow the patient to sleep as long as he feels sleepy c) stimulate the patient to increase his level of consciousness d) check the patient's level of consciousness every 15 minutes for an hour 10. The nurse finds a patient in bed having a generalized tonic-clonic seizure. During the seizure activity, the nurse should: a) turn the patient to the side b) suction the patient and administer oxygen c) insert an oral airway into the patient's mouth d) restrain the patient's extremities to prevent soft tissue and bone injury 11. When teaching a patient with a seizure disorder about the medication regimen, it is most important for the nurse to stress that: a) the patient should increase the dosage of the medication if stress is increased b) if gingival hypertrophy occurs the drug should be stopped and the health care provider notified c) stopping the medication abruptly may increase the intensity and frequency of seizures d) most over-the-counter and prescription drugs are safe to take with anticonvulsant drugs 12. A patient admitted to the hospital following a generalized tonic-clonic seizure asks the nurse what caused the seizure. The best response by the nurse is: a) "So many factors can cause epilepsy that it is impossible to say what caused your seizure." b) "Epilepsy is an inherited disorder. Does anyone else in your family have a seizure disorder?" c) "In seizures, some type of trigger causes sudden, abnormal bursts of electrical brain activity." d) "Scar tissue in the brain alters the chemical balance, creating uncontrolled electrical discharges." 13. Generalized seizures differ from partial seizures in that: a)Partial seizure are confined to one side of the brain and remain focal in nature b)Generalized seizures result in loss of consciousness while partial seizures do not. c)Generalized seizures result in temporary residual deficits during the postictal phase. d)Generalized seizures have no warning because the entire brain is affected at the onset. 14. The client experiences low back pain near the end of each day. The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions will the nurse plan to include in teaching the client about preventing low back pain and injury? Select all that apply. A. "Standing for long periods of time will help to prevent low back pain." B. "Keep weight within 50% of ideal body weight." C. "Begin a regular exercise program." D. "When lifting something, the back should be straight and the knees bent." E. "Do not wear high-heeled shoes." 15. The client is admitted with a spinal cord injury at the fifth thoracic vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? A. Auscultating bowel sounds every 2 hours B. Beginning a bladder retraining program C. Monitoring nutritional status D. Positioning the client to maximize ventilation potential 16. To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the health care team is a nursing priority? A. Nutritional therapy B. Occupational therapy C. Physical therapy D. Respiratory therapy 17. In addition to frequent repositioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury? A. Gel pad B. TED (thromboembolism disease) hose C. Trapeze D. Water bottle 18. The nurse is teaching the client and her husband about sexuality issues after a spinal cord injury. Which comment by the client indicates understanding of the nurse's instruction? A. "I can no longer become pregnant." B. "If I become pregnant, I cannot give birth." C. "I may still be able to get pregnant." D. "My children will be paralyzed." 19. The client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates understanding of the nurse's instruction? A. "I can go home the day of the procedure." B. "I can go home 48 hours after the procedure." C. "I'll have a drain in place after the procedure." D. "I'll need to wear special stockings after the procedure." 20. In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? A. Patent airway B. Indication of allergies C. Level of consciousness D. Loss of sensation 21. In assessing the client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? A. Gait B. Mobility C. Sensation D. Strength 22. Which nursing intervention is best for preventing complications of immobility when caring for the client with spinal cord health problems? A. Frequent ambulation B. Proper positioning C. Regular turning and repositioning D. Special pressure relief devices 23. The client who has just undergone spinal surgery must be moved. How will the nurse plan to move this client? A. Getting the client up in a chair B. Keeping the client in the Trendelenburg position C. Lifting the client in unison with other health care personnel D. Log rolling the client 24. The nurse is providing instructions to a client with a spinal injury about caring for the halo device. The nurse plans to include which instructions? A. Begin driving 1 week after discharge. B. Avoid using a pillow under the head while sleeping. C. Swimming is recommended to keep active. D. Keep straws available for drinking fluids. 25. The client with a spinal cord tumor and a poor prognosis has lost bladder control. The client asks the nurse whether the suggested surgery will be "worth it." What is the nurse's best response? A. "It should help return bladder control." B. "Let me call the surgeon so you can ask the rest of your questions." C. "What do you think?" D. "What does your family think?" 26. The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will request which medication? A. Dopamine hydrochloride (Inotropin) B. Hydralazine (Apresoline) C. Methylprednisolone (Solu-Medrol) D. Ziconotide (Prialt) 27. The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? A. Neck pain is at a level 7 (0 to 10 scale). B. The client has hoarseness and some difficulty swallowing secretions. The client has numbness and tingling bilaterally down the arms. C. The client has numbness and tingling bilaterally down the arms. D. Serosanguineous fluid oozes onto the neck dressing. 28. The nurse is caring for a client in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action? A. Electrocardiographic monitoring shows a sinus bradycardia at a rate of 50. B. The client demonstrates flaccid paralysis below the level of injury. C. The client's chest moves very little with each respiration. D. After two fluid boluses, the client's systolic blood pressure remains 80. 29. A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action will the nurse take first? A. Check for fecal impaction. B. Insert a straight catheter. C. Help the client sit up. D. Loosen the client's clothing. 30. When providing discharge teaching to a client after a lumbar laminectomy, the nurse teaches him or her to call the surgeon immediately for which potential complication? A. Discomfort at the incision site B. Decreased appetite in the morning C. Slight redness and itching at the incision site D. Clear drainage from the incision site 31. A client was admitted this morning with an incomplete spinal cord injury and is placed in a halo fixator vest after surgery. Which assessment finding will the nurse report immediately to the health care provider? A. Pulse rate of 78 beats/min B. Blood pressure of 88/42 mm Hg C. Pain level of 4 on a 0-to-10 pain scale D. Loosened halo vest 32. The client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What will the nurse do next? A. Allow the client to remain undisturbed. B. Assess the client's vital signs. C. Remove the cloth because it can harbor microorganisms. D. Turn on the lights for a neurologic assessment. 33. The nurse is teaching the client newly diagnosed with migraine about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A. "I can still eat Chinese food." B. "I must not miss meals." C. "It is okay to drink a few wine coolers." D. "I need to use fake sugar in my coffee." 34. The client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A. Stroke B. Tension headache C. Classic migraine D. Cluster headache