100% CORRECT ANSWERS!!
1 of 50
Term
A patient with hypertension is placed on a low-sodium diet. The
nurse recognizes that further teaching is necessary if the
patient chooses which menu?
A. Pork chop, steamed brown rice, and fruit cocktail
B.Broiled salmon, mashed sweet potato, broccoli, and pumpkin pie
C. Tomato soup, grilled cheese sandwich, salad, and chocolate chip
cookie
D.Grilled chicken, boiled potatoes, frozen green beans, and gelatin
dessert
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A. Monitor BP every 5 minutes.
D. Check to see if the indwelling catheter is patent.
E. Perform a rectal examination to determine if impaction is present.
1. The patient is experiencing autonomic dysreflexia, which can cause
hypertension and bradycardia. The nurse should monitor BP and then check for
catheter patency and impaction, both of which can cause dysreflexia.
2. The patient should be placed in high Fowler position, and elastic
stockings should be removed to allow blood to pool and reduce BP.
3. The patient should be placed in high Fowler position, and elastic
stockings should be removed to allow blood to pool and reduce BP.
4. The patient is experiencing autonomic dysreflexia, which can cause
hypertension and bradycardia. The nurse should monitor BP and then check for
catheter patency and impaction, both of which can cause dysreflexia.
5. The patient is experiencing autonomic dysreflexia, which can cause
hypertension and bradycardia. The nurse should monitor BP and then check for
catheter patency and impaction, both of which can cause dysreflexia.
Answer 1: Palpation
Answer 2: Technique
Answer 3:Demonstration
A. Evaluate level of consciousness
D. Regulate hydration according to the intake and output
E. Implement seizure precautions
C. Tomato soup, grilled cheese sandwich, salad, and chocolate chip cookie
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2 of 50
Term
, The nurse is caring for a client who had an intracerebral
hemorrhagic stroke. The family members are concerned about how
this could happen. Without knowing the cause of this client's stroke,
the nurse correctly informs the family that which of the following is
the number one reason for intracerebral hemorrhagic stroke?
A. Chronic hypertension
B.Heparin use
C. Tachycardia
D. Fall
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A. Avoid hip flexion.
B.Administer stool softeners.
C. Keep head of bed elevated A. Chronic hypertension
30 degrees.
A. Carry a pacemaker identification D.A patient with atrial
card. fibrillation reporting dyspnea
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3 of 50
Term
A nurse is caring for two clients that have been admitted to the unit
with a hemorrhagic stroke. The nurse assistant gives the the
following vitals for the two clients. Which of the following abnormal
vital signs is the most concerning?
A. 210/112 mmHg BP
, B.130 heart rate
C. 90/53 mmHg BP
D.55 heart rate
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A. Hemorrhage
A client on a blood thinner will always be monitored for hemorrhage. If the client
falls, there is a high risk of greater than normal blood loss from hemorrhage. The
provider would need to be notified, and a CT of the head and abdomen
would be completed to make sure there isn't a brain bleed or any internal
abdominal
bleeding.
A. 210/112 mmHg BP
High BP with hemorrhagic strokes are concerning for causing increased
amount of brain bleeding. Hypertension is the main cause of hemorrhagic
stroke and this increases the risk of bleeding more.
B.Ask the client to squeeze the nurse's fingers
C. Have the client flex and extend the feet
D.Tell the client to push his or her arms away from the nurse
C. Check the patient's mouth periodically for presence of pocketed food.
The nurse checks the patient's mouth periodically for pocketed food, which
commonly occurs in patients with swallowing issues.
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4 of 50
Term