NUR 480 XAM 3 2025 UPDATE QUESTIONS AND CORRECT VERIFIED
ANSWERS ALREADY GRADED A+ (BRAND NEW VISION)
In planning for discharge planning for a client with bacterial meningitis, the nurse will be sure to
include which instruction?
1. Keep all family and visitors from visiting your room for protective isolation.
2. Make sure you eat high protein diet with plenty of fluids
3. Take all of the antibiotics until gone.
4. Incorporate regular exercise with an active range of motion. - answers3. Take all of the
antibiotics until gone.
The client should be instructed to complete all antibiotics until they are completely gone.
Failure to complete antibiotics may lead to re-infection and may spread causing endocarditis
and other infections in the body, especially if the bacteria were from streptococci. While the
client may be in isolation while in the hospital, family may not need to quarantine the client
when at home. Some family members receive prophylactic antibiotics, but will be ordered
according to the bacterial strain and health care provider (HCP) recommendations. It is
important to eat a good diet, but the most important will be taking prescribed antibiotics.
While returning to exercise is important, gradual increase should be performed, and the
answer selection for exercise was not as important as prescribed antibiotics.
The nurse is assessing the central stimulus function of an unconscious client in the intensive
care unit. The nurse should plan to use which technique to test the client's central response to
stimuli?
1. Supraorbital ridge pressure.
2. Sternal rub.
3. Pressure on the nail bed.
4. Calling out loudly close to the client's ear. - answers1. Supraorbital ridge pressure.
,Central stimulus is applied to cranial nerves not peripheral nerves. Supraorbital ridge pressure
by applying pressure on the orbital rim is indicated for central stimulus assessment. Sternal
rub is usually not indicated via best practices. Pressure on the nail bed represents testing
painful stimuli for motor testing on peripheral nerves. Calling out loudly is not an assessment
technique for central stimulus function. There are two anatomic locations for pain stimulus:
centrally and peripherally. Central involves trapezious pinch or supraorbital pressure whereas
peripheral stimuli are applied to extremities. Responses may infer damage to the brain or
specific brain areas.
A client is admitted for observation following a motor vehicle accident that occurred on the way
to the client's daughter's wedding. The next morning, instead of asking about the wedding, the
client tells the nurse "I have to leave now since the wedding is in a few minutes." The client then
becomes agitated when the nurse re-orients and states the actual date (which is the day
following the wedding). What should the nurse do next?
1. Change the date on the hospital room whiteboard to yesterday's date.
2. Perform neurological assessment and assess pupillary response.
3. Administer Valium 40 mg IV since the client is about to have a seizure.
4. Call the family to see if the wedding can be repeated - answers2. Perform neurological
assessment and assess pupillary response.
The nurse needs to perform a neuro assessment to determine pupillary response, ask if a
headache is present, take vital signs, and contact the health care provider. The client may be
exhibiting subtle signs of increased intracranial pressure which includes restlessness,
agitation, headache, and pupil changes.
A client is taking infelbamate (Felbatol) for seizures and displays symptoms of pancytopenia
based on which assessment findgs? (Select all that apply)
1. Sore throat
,2. Epistaxis
3. Skin rash
4. Gingival hyperplasia - answers1. Sore throat
2. Epistaxis
Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-like feeling, and
may exhibit increased bleeding with reduced platelet count (epitaxis). Skin rash may not
indicate pancytopenia. Gingival hyperplasia is an adverse affect of anticonvulsants like
phenytoin, but is not a symptom of pancytopenia. Pancytopenia affects red cells, white cells,
and platelets and represents bone marrow's response to on-hematologic conditions such as
drugs.
A client is being discharged with a new prescription of phenytoin sodium (dilantin). Which
instruction by the nurse is most important to include?
1. If stopped abruptly, status epilepticus may occur.
2. Sulfonamides like Bactrim will decrease phenytoin levels in the blood.
3. Take the medication with antacids to reduce gastric upset.
4. Dilantin will not affect contraceptive effectiveness. - answers1. If stopped abruptly, status
epilepticus may occur.
It is important to instruct not to suddenly stop taking phenytoin sodium (Dilantin) as doing so
may present a risk for return of life-threatening seizure activity. Sulfonamides will increase
phenytoin levels. The drug should not be taken with antacids and will lower phenytoin
absorption. Clients on contraceptive hormone therapy may need to use alternative forms of
non-hormonal contraceptives while on phenytoin sodium (Dilantin).
The nurse is caring for a client who is unconscious who requires enteral feedings through a
nasogastric tube. Which action takes priority when managing enteral feedings?
, 1. Weigh the client daily at the same time.
2. Make sure sterile water and sterile gavage system is changed every 24 hours.
3. Keep the client in semi-fowlers position.
4. Keep the formula warm by setting in hot water 30 minutes prior to administration. -
answers3. Keep the client in semi-fowlers position.
It is most important to maintain a semi-flowlers position with nasogastric feedings to prevent
aspiration. While daily weights may be important, protecting the airway and lungs from
aspiration is more important. Having sterile water and supplies are not necessary since the
management is with clean not sterile procedure. The formula should be room temperature
and should never be heated prior to administration.
The nurse will collaborate with the interdisciplinary team on communication assist with a client
with expressive aphasia. The team decided on which intervention to help with communication?
1. Make sure all staff know to speak slowly and in short sentences.
2. Make sure all staff speak loudly for the client to hear.
3. Make sure all staff write on a clipboard for the client to read communication.
4. Make sure all staff assist the client with use of a picture board which is client driven. -
answers4. Make sure all staff assist the client with use of a picture board which is client
driven.
Expressive aphasia clients may understand what is heard or written, but they may not be able
to verbally communicate their needs. A picture or communication board helps the client as
the client can point to or direct others towards objects on the board for wants and needs.
Speaking loudly or slowly is not therapeutic for communication and may diminish the client's
dignity. Having staff to be the only ones to write implies one-way communication that is staff-
driven and not client-need driven. The focus is client-centered care and the client should be
encouraged to express needs and wants through therapeutic means.
ANSWERS ALREADY GRADED A+ (BRAND NEW VISION)
In planning for discharge planning for a client with bacterial meningitis, the nurse will be sure to
include which instruction?
1. Keep all family and visitors from visiting your room for protective isolation.
2. Make sure you eat high protein diet with plenty of fluids
3. Take all of the antibiotics until gone.
4. Incorporate regular exercise with an active range of motion. - answers3. Take all of the
antibiotics until gone.
The client should be instructed to complete all antibiotics until they are completely gone.
Failure to complete antibiotics may lead to re-infection and may spread causing endocarditis
and other infections in the body, especially if the bacteria were from streptococci. While the
client may be in isolation while in the hospital, family may not need to quarantine the client
when at home. Some family members receive prophylactic antibiotics, but will be ordered
according to the bacterial strain and health care provider (HCP) recommendations. It is
important to eat a good diet, but the most important will be taking prescribed antibiotics.
While returning to exercise is important, gradual increase should be performed, and the
answer selection for exercise was not as important as prescribed antibiotics.
The nurse is assessing the central stimulus function of an unconscious client in the intensive
care unit. The nurse should plan to use which technique to test the client's central response to
stimuli?
1. Supraorbital ridge pressure.
2. Sternal rub.
3. Pressure on the nail bed.
4. Calling out loudly close to the client's ear. - answers1. Supraorbital ridge pressure.
,Central stimulus is applied to cranial nerves not peripheral nerves. Supraorbital ridge pressure
by applying pressure on the orbital rim is indicated for central stimulus assessment. Sternal
rub is usually not indicated via best practices. Pressure on the nail bed represents testing
painful stimuli for motor testing on peripheral nerves. Calling out loudly is not an assessment
technique for central stimulus function. There are two anatomic locations for pain stimulus:
centrally and peripherally. Central involves trapezious pinch or supraorbital pressure whereas
peripheral stimuli are applied to extremities. Responses may infer damage to the brain or
specific brain areas.
A client is admitted for observation following a motor vehicle accident that occurred on the way
to the client's daughter's wedding. The next morning, instead of asking about the wedding, the
client tells the nurse "I have to leave now since the wedding is in a few minutes." The client then
becomes agitated when the nurse re-orients and states the actual date (which is the day
following the wedding). What should the nurse do next?
1. Change the date on the hospital room whiteboard to yesterday's date.
2. Perform neurological assessment and assess pupillary response.
3. Administer Valium 40 mg IV since the client is about to have a seizure.
4. Call the family to see if the wedding can be repeated - answers2. Perform neurological
assessment and assess pupillary response.
The nurse needs to perform a neuro assessment to determine pupillary response, ask if a
headache is present, take vital signs, and contact the health care provider. The client may be
exhibiting subtle signs of increased intracranial pressure which includes restlessness,
agitation, headache, and pupil changes.
A client is taking infelbamate (Felbatol) for seizures and displays symptoms of pancytopenia
based on which assessment findgs? (Select all that apply)
1. Sore throat
,2. Epistaxis
3. Skin rash
4. Gingival hyperplasia - answers1. Sore throat
2. Epistaxis
Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-like feeling, and
may exhibit increased bleeding with reduced platelet count (epitaxis). Skin rash may not
indicate pancytopenia. Gingival hyperplasia is an adverse affect of anticonvulsants like
phenytoin, but is not a symptom of pancytopenia. Pancytopenia affects red cells, white cells,
and platelets and represents bone marrow's response to on-hematologic conditions such as
drugs.
A client is being discharged with a new prescription of phenytoin sodium (dilantin). Which
instruction by the nurse is most important to include?
1. If stopped abruptly, status epilepticus may occur.
2. Sulfonamides like Bactrim will decrease phenytoin levels in the blood.
3. Take the medication with antacids to reduce gastric upset.
4. Dilantin will not affect contraceptive effectiveness. - answers1. If stopped abruptly, status
epilepticus may occur.
It is important to instruct not to suddenly stop taking phenytoin sodium (Dilantin) as doing so
may present a risk for return of life-threatening seizure activity. Sulfonamides will increase
phenytoin levels. The drug should not be taken with antacids and will lower phenytoin
absorption. Clients on contraceptive hormone therapy may need to use alternative forms of
non-hormonal contraceptives while on phenytoin sodium (Dilantin).
The nurse is caring for a client who is unconscious who requires enteral feedings through a
nasogastric tube. Which action takes priority when managing enteral feedings?
, 1. Weigh the client daily at the same time.
2. Make sure sterile water and sterile gavage system is changed every 24 hours.
3. Keep the client in semi-fowlers position.
4. Keep the formula warm by setting in hot water 30 minutes prior to administration. -
answers3. Keep the client in semi-fowlers position.
It is most important to maintain a semi-flowlers position with nasogastric feedings to prevent
aspiration. While daily weights may be important, protecting the airway and lungs from
aspiration is more important. Having sterile water and supplies are not necessary since the
management is with clean not sterile procedure. The formula should be room temperature
and should never be heated prior to administration.
The nurse will collaborate with the interdisciplinary team on communication assist with a client
with expressive aphasia. The team decided on which intervention to help with communication?
1. Make sure all staff know to speak slowly and in short sentences.
2. Make sure all staff speak loudly for the client to hear.
3. Make sure all staff write on a clipboard for the client to read communication.
4. Make sure all staff assist the client with use of a picture board which is client driven. -
answers4. Make sure all staff assist the client with use of a picture board which is client
driven.
Expressive aphasia clients may understand what is heard or written, but they may not be able
to verbally communicate their needs. A picture or communication board helps the client as
the client can point to or direct others towards objects on the board for wants and needs.
Speaking loudly or slowly is not therapeutic for communication and may diminish the client's
dignity. Having staff to be the only ones to write implies one-way communication that is staff-
driven and not client-need driven. The focus is client-centered care and the client should be
encouraged to express needs and wants through therapeutic means.
