NURS 300 MED SURG FINAL EXAM QUESTIONS
WITH VERIFIED SOLUTIONS TESTED AND
APPROVED!!!
The client diagnosed with a right-sided
cerebrovascular accident is admitted to the
rehabilitation unit. Which interventions should be
included in the nursing care plan? Select all that
apply.
1. Position the client to prevent shoulder
adduction.
2. Turn and reposition the client every shift.
3. Encourage the client to move the affected side.
4. Perform quadriceps exercises three (3) times a
day.
5. Instruct the client to hold the fingers in a fist. --CORRECT ANSWER--1, 3
1. Placing a small pillow under the shoulder
will prevent the shoulder from adduct-
ing toward the chest and developing a
contracture.
Page 1 of 128
,3. The client should not ignore the para-
lyzed side, and the nurse must encourage
the client to move it as much as possible;
a written schedule may assist the client in
exercising.
The nurse is planning care for a client experiencing
agnosia secondary to a cerebrovascular accident.
Which collaborative intervention will be included
in the plan of care?
1. Observe the client swallowing for possible
aspiration.
2. Position the client in a semi-Fowler's position
when sleeping.
3. Place a suction setup at the client's bedside
during meals.
4. Refer the client to an occupational therapist for
evaluation. --CORRECT ANSWER--4.Refer the client to an occupational
therapist for evaluation.
A collaborative intervention is an intervention in which another health-care
discipline in this case, occupational therapy is used in the care of the client.
Page 2 of 128
,The nurse and an unlicensed assistive personnel (UAP) are caring for a client
with right-sided paralysis. Which action by the UAP requires the nurse to
intervene?
1. The assistant places a gait belt around the client's waist prior to ambulating.
2.The assistant places the client on the back with the client's head to the side.
3.The assistant places a hand under the client's right axilla to move up in bed.
4.The assistant praises the client for attempting to perform ADLs independently.
--CORRECT ANSWER--3.The assistant places a hand under the client's right
axilla to move up in bed.
This action is inappropriate and would require intervention by the nurse because
pulling on a flaccid shoulder joint could cause shoulder dislocation; the client
should be pulled up by placing the arm underneath the back or using a lift sheet.
A 78-year-old client is admitted to the emergency
department (ED) with numbness and weakness of
the left arm and slurred speech. Which nursing
intervention is a priority?
1. Prepare to administer recombinant tissue
plasminogen activator (rt-PA).
2. Discuss the precipitating factors that caused
the symptoms.
Page 3 of 128
, 3. Schedule for a STAT computed tomography
(CT) scan of the head.
4. Notify the speech pathologist for an emergency
consult. --CORRECT ANSWER--3. A CT scan will determine if the client is
having a stroke or has a brain tumor or
another neurological disorder. If a CVA is
diagnosed, the CT scan can determine if it
is a hemorrhagic or an ischemic
accident and guide treatment.
The nurse is assessing a client experiencing motor
loss as a result of a left-sided cerebrovascular
accident (CVA). Which clinical manifestation would the nurse document?
1. Hemiparesis of the client's left arm and apraxia.
2. Paralysis of the right side of the body and
ataxia.
3. Homonymous hemianopsia and diplopia.
4. Impulsive behavior and hostility toward family. --CORRECT ANSWER--2.
The most common motor dysfunction of
a CVA is paralysis of one side of the body,
hemiplegia; in this case with a left-sided
Page 4 of 128
WITH VERIFIED SOLUTIONS TESTED AND
APPROVED!!!
The client diagnosed with a right-sided
cerebrovascular accident is admitted to the
rehabilitation unit. Which interventions should be
included in the nursing care plan? Select all that
apply.
1. Position the client to prevent shoulder
adduction.
2. Turn and reposition the client every shift.
3. Encourage the client to move the affected side.
4. Perform quadriceps exercises three (3) times a
day.
5. Instruct the client to hold the fingers in a fist. --CORRECT ANSWER--1, 3
1. Placing a small pillow under the shoulder
will prevent the shoulder from adduct-
ing toward the chest and developing a
contracture.
Page 1 of 128
,3. The client should not ignore the para-
lyzed side, and the nurse must encourage
the client to move it as much as possible;
a written schedule may assist the client in
exercising.
The nurse is planning care for a client experiencing
agnosia secondary to a cerebrovascular accident.
Which collaborative intervention will be included
in the plan of care?
1. Observe the client swallowing for possible
aspiration.
2. Position the client in a semi-Fowler's position
when sleeping.
3. Place a suction setup at the client's bedside
during meals.
4. Refer the client to an occupational therapist for
evaluation. --CORRECT ANSWER--4.Refer the client to an occupational
therapist for evaluation.
A collaborative intervention is an intervention in which another health-care
discipline in this case, occupational therapy is used in the care of the client.
Page 2 of 128
,The nurse and an unlicensed assistive personnel (UAP) are caring for a client
with right-sided paralysis. Which action by the UAP requires the nurse to
intervene?
1. The assistant places a gait belt around the client's waist prior to ambulating.
2.The assistant places the client on the back with the client's head to the side.
3.The assistant places a hand under the client's right axilla to move up in bed.
4.The assistant praises the client for attempting to perform ADLs independently.
--CORRECT ANSWER--3.The assistant places a hand under the client's right
axilla to move up in bed.
This action is inappropriate and would require intervention by the nurse because
pulling on a flaccid shoulder joint could cause shoulder dislocation; the client
should be pulled up by placing the arm underneath the back or using a lift sheet.
A 78-year-old client is admitted to the emergency
department (ED) with numbness and weakness of
the left arm and slurred speech. Which nursing
intervention is a priority?
1. Prepare to administer recombinant tissue
plasminogen activator (rt-PA).
2. Discuss the precipitating factors that caused
the symptoms.
Page 3 of 128
, 3. Schedule for a STAT computed tomography
(CT) scan of the head.
4. Notify the speech pathologist for an emergency
consult. --CORRECT ANSWER--3. A CT scan will determine if the client is
having a stroke or has a brain tumor or
another neurological disorder. If a CVA is
diagnosed, the CT scan can determine if it
is a hemorrhagic or an ischemic
accident and guide treatment.
The nurse is assessing a client experiencing motor
loss as a result of a left-sided cerebrovascular
accident (CVA). Which clinical manifestation would the nurse document?
1. Hemiparesis of the client's left arm and apraxia.
2. Paralysis of the right side of the body and
ataxia.
3. Homonymous hemianopsia and diplopia.
4. Impulsive behavior and hostility toward family. --CORRECT ANSWER--2.
The most common motor dysfunction of
a CVA is paralysis of one side of the body,
hemiplegia; in this case with a left-sided
Page 4 of 128
