NUR 221 EXAM 1 | 2024 Questions & Answers |
100% Correct | Verified
The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by
the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30
breaths/min, and temperature of 100.5° F. The patient is lethargic,
responds to voice but falls asleep readily when not stimulated. Which nursing action is most important
to include in this patient's plan of care?
A. Frequent neurological assessments
B. Side to side position changes
C. Range of motion to extremities
D. Frequent oropharyngeal suctioning - ✔✔A. Frequent neurological assessments
The nurse has just received a patient from the emergency department with an admitting diagnosis of
bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best
action by the nurse?
A. Implement droplet precautions upon admission.
B. Wash hands thoroughly before leaving the room.
C. Scrub the hub of all central line ports prior to use.
D. Dispose of all bloody dressings in biohazard bags. - ✔✔A. Implement droplet precautions upon
admission.
The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse
include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min,
oxygen saturation (SpO 2 ) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is
the priority nursing action?
,A. Elevate the head of the bed 30 degrees.
B. Keep lights dim at all times.
C. Implement seizure precautions.
D. Maintain bed rest at all times. - ✔✔C. Implement seizure precautions.
A patient seeks treatment for progressively deteriorating motor and sensory function. What question is
essential for the nurse to ask when completing this patient's health history?
A. "Have you been around any small children?"
B. "When was the last time you had anything to eat?"
C. "When was the last time you traveled out of the country?"
D. "Have you recently experienced any lung or stomach infections?" - ✔✔D. "Have you recently
experienced any lung or stomach infections?"
A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the nurse
respond about the pathophysiology of the disorder?
A. "An infection eats away at the nerve endings."
B. "An infection enters the spinal cord and erodes the nerves at the roots."
C. "The nerves are killed by infiltration of your body's white blood cells used to fight an infection."
D. "After an infection your immune system created antibodies that affect the covering of the nerves." -
✔✔D. "After an infection your immune system created antibodies that affect the covering of the nerves."
A patient is experiencing bilateral symmetrical muscle weakness and sensory changes of both feet and
legs. What should the nurse expect to assess that determines the presence of Guillain-Barré syndrome
(GBS)?
A. Areflexia
, B. Hyporeflexia
C. Hyperreflexia
D. Hyperanalgesia - ✔✔A. Areflexia
A patient with Guillain-Barré syndrome (GBS) loses respiratory function three weeks into the acute
phase. When should the nurse expect respiratory function to return in this patient?
A. During the plateau phase
B. Early in the recovery stage
C. At the end of the plateau stage
D. At the end of the recovery stage - ✔✔B. Early in the recovery stage
A patient with progressively deteriorating lower extremity motor and sensory function is having a lumbar
puncture. What finding suggests that this patient has Guillain-Barré syndrome (GBS)?
A. Elevated protein level
B. Elevated glucose level
C. Reduction in white blood cell count
D. Increased number of red blood cells - ✔✔A. Elevated protein level
A patient with Guillain-Barré syndrome (GBS) is receiving plasmapheresis. What finding should the nurse
identify as being a complication of this treatment?
A. Septicemia
B. Flu-like symptoms
C. Aseptic meningitis
D. Acute renal failure - ✔✔A. Septicemia
100% Correct | Verified
The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by
the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30
breaths/min, and temperature of 100.5° F. The patient is lethargic,
responds to voice but falls asleep readily when not stimulated. Which nursing action is most important
to include in this patient's plan of care?
A. Frequent neurological assessments
B. Side to side position changes
C. Range of motion to extremities
D. Frequent oropharyngeal suctioning - ✔✔A. Frequent neurological assessments
The nurse has just received a patient from the emergency department with an admitting diagnosis of
bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best
action by the nurse?
A. Implement droplet precautions upon admission.
B. Wash hands thoroughly before leaving the room.
C. Scrub the hub of all central line ports prior to use.
D. Dispose of all bloody dressings in biohazard bags. - ✔✔A. Implement droplet precautions upon
admission.
The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse
include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min,
oxygen saturation (SpO 2 ) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is
the priority nursing action?
,A. Elevate the head of the bed 30 degrees.
B. Keep lights dim at all times.
C. Implement seizure precautions.
D. Maintain bed rest at all times. - ✔✔C. Implement seizure precautions.
A patient seeks treatment for progressively deteriorating motor and sensory function. What question is
essential for the nurse to ask when completing this patient's health history?
A. "Have you been around any small children?"
B. "When was the last time you had anything to eat?"
C. "When was the last time you traveled out of the country?"
D. "Have you recently experienced any lung or stomach infections?" - ✔✔D. "Have you recently
experienced any lung or stomach infections?"
A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the nurse
respond about the pathophysiology of the disorder?
A. "An infection eats away at the nerve endings."
B. "An infection enters the spinal cord and erodes the nerves at the roots."
C. "The nerves are killed by infiltration of your body's white blood cells used to fight an infection."
D. "After an infection your immune system created antibodies that affect the covering of the nerves." -
✔✔D. "After an infection your immune system created antibodies that affect the covering of the nerves."
A patient is experiencing bilateral symmetrical muscle weakness and sensory changes of both feet and
legs. What should the nurse expect to assess that determines the presence of Guillain-Barré syndrome
(GBS)?
A. Areflexia
, B. Hyporeflexia
C. Hyperreflexia
D. Hyperanalgesia - ✔✔A. Areflexia
A patient with Guillain-Barré syndrome (GBS) loses respiratory function three weeks into the acute
phase. When should the nurse expect respiratory function to return in this patient?
A. During the plateau phase
B. Early in the recovery stage
C. At the end of the plateau stage
D. At the end of the recovery stage - ✔✔B. Early in the recovery stage
A patient with progressively deteriorating lower extremity motor and sensory function is having a lumbar
puncture. What finding suggests that this patient has Guillain-Barré syndrome (GBS)?
A. Elevated protein level
B. Elevated glucose level
C. Reduction in white blood cell count
D. Increased number of red blood cells - ✔✔A. Elevated protein level
A patient with Guillain-Barré syndrome (GBS) is receiving plasmapheresis. What finding should the nurse
identify as being a complication of this treatment?
A. Septicemia
B. Flu-like symptoms
C. Aseptic meningitis
D. Acute renal failure - ✔✔A. Septicemia
