ADULT HEALTH 3 EXAM STUDY GUIDE- LATEST

ADULT HEALTH 3 EXAM STUDY GUIDE- LATEST 1. The nurse on the neurological unit is positioning a client who had a stroke two days ago and had left-sided hemiparesis. Which of the following actions by the nurse would be appropriate? Select all that apply. a. Positioning a rolled washcloth in the client’s left hand b. Placing a foam abduction wedge between the client’s legs c. Grasping the client’s left arm to pull the client from supine to a right side-lying position d. Securing the left arm in a sling e. Putting a trochanter roll on the outside of the client’s left hip when the client is supine. 2. The nurse is caring for a client who has expressive aphasia following a stroke. The nurse has taught the client’s spouse about ways to facilitate communication. Which of the following comments by the client’s spouse would require follow-up? a. “I wait after I ask my spouse a question, to give as much time as needed to answer.” b. “I ask my spouse questions like, ‘Do you like this movie?’ instead of ‘What do you think of this movie?’” c. “I act like I understand when I do not, so that my spouse will not become frustrated.” d. “I tell my spouse, ‘Point to what you want” so I do not get frustrated trying to understand.” 3. The nurse is caring for a client with increased intracranial pressure (ICP) who has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following prescribed interventions should the nurse implement? a. Electrolyte restriction b. Electrolyte replacement c. Fluid replacement d. Fluid restriction 4. The nurse is planning care for a client who has a recent diagnosis of multiple sclerosis (MS). Which of the following interventions should the nurse include in the client’s care plan? a. Instruct the client on daily muscle stretching exercises b. Provide total assistance with all activities of daily living (ADLs) c. Encourage the client to follow a low-residue diet d. Encourage client to void every hour 5. The nurse is caring for a group of assigned clients. Which of the following client’s should the nurse see first? a. The client with ulcerative colitis who reports left lower quadrant abdominal pain and passing stools that appear bloody with mucus and pus. b. The client with breast cancer receiving prescribed chemotherapy whose platelet count is 52,000/uL and reports having shaking chills. c. The client with hepatitis B virus who was admitted with jaundice and now has changes in cognitive function. d. The client recovering from an ischemic stroke who has decreased lung sounds, productive cough and a temperature of 104.8 F. 6. The nurse is planning an education conference about anticoagulation and the direct factor Xa inhibitor medications. Select all that apply. a. Aspirin b. Coumadin c. Dipyridamole d. Rivaroxaban e. Apixaban 7. The nurse in an outpatient setting is assessing a client’s risk for ischemic stroke. The nurse should assess for which of the following conditions? Select all that apply. a. Atrial fibrillation b. Hemophilia c. Diabetes Mellitus d. Epilepsy e. Concussion f. Carotid Stenosis 8. The nurse is caring for a client with a traumatic brain injury (TBI) following a fall. Which of the following medications should the nurse anticipate being prescribed for the client to reduce cerebral edema? a. Mannitol b. Spirolactone c. Furosemide d. Hydrochlorothiazide 9. The nurse is preparing to administer prescribed dexamethasone 7.5 mg daily in divided doses every 6 hours to a client with vasogenic edema. The nurse has 10 mg/mL available. How many mL per dose should the nurse administer? Round your answer to the nearest tenth place. 10. The nurse is preparing to prescribe bevacizumab 10 mg/kg, IV, every 14 days for a client with a glioblastoma. The client weighs 160 lbs. The nurse has available 25 mg/mL. How many mL per dose should the nurse administer to the client? 11. The nurse is admitting a 16-year-old client who returned home early from summer camp with fever, severe headache, and vomiting. Which of the following prescribed interventions should the nurse implement first? a. Prepare the client for lumbar puncture b. Administer antibiotics and pain medication c. Decrease body temperature d. Collect a specimen for blood culture 12. The nurse is planning care for a client who has homonymous hemianopsia following a right hemispheric stroke. Which of the following interventions should the nurse include in the clients plan of care? a. Avoid using bright lights in the client’s room b. Position objects on the clients left side c. Stand in front of the client when speaking d. Tell the client how far or close objects are to the client 13. The nurse is caring for a client who had a right hemispheric stroke and has been evaluated by the speech therapist. The client has motor and visual deficits. During the clients first meal, since having a stroke, which of the following actions should the nurse take? a. Encourage the client to swallow twice after chewing each bite of food. b. Instruct the client to place food on the left side of the mouth c. Remind the client to rotate the head to scan for food items on the right side of the plate. d. Verify that all the client’s foods have been pureed. 14. The nurse has a prescription for a hypertonic saline solution for a client to be administered at 80 ml/her with a drop factor of 20 gtt/ml. How many gtt/min should the nurse administer to the client? 15. The nurse has provided information about urinary elimination to the spouse of a female client who recently had a stroke. Which of the following statements by the client’s spouse would indicate a correct understanding of the information? Select all that apply. a. “I will encourage bladder emptying every two hours.” b. “it is good to limit oral fluid intake after seven o’clock in the evening.” c. “It is best if pants have elastic waistbands instead of buttons.” d. “I will use a bedpan at nighttime and make sure I sit my spouse upright.” e. “I will learn how to care for a long-term urinary catheterization.” 16. The nurse is caring for a client who suffered a skull fracture 6 hours ago and has a positive halo sign, or ring sign. The nurse should recognize that this finding is associated with an increased risk for which of the following? a. Post-concussion syndrome b. Tentorial herniation c. Meningitis d. Coma 17. The nurse is caring for a client who has a ventriculostomy. Which of the following actions by the nurse would be appropriate? a. Positioning the transducer at the level of the client’s ear b. Performing respiratory suctioning at scheduled 2-hour intervals c. Allowing cerebrospinal fluid drainage for 30 minutes at a time d. Maintaining the client in a supine position 18. The nurse is planning care for a client in the emergency department (ED) with an open fracture of the radius. The nurse should include which of the following interventions as a priority in the client’s plan of care? a. Prepare client for cast placement b. Cover the wound with a sterile dressing c. Irrigate the wound d. Elevate the affected extremity 19. The nurse is caring for a client that has a ventriculostomy for monitoring increased intracranial pressure (ICP). Which of the following would indicate to the nurse that the client is experiencing a complication of the ventriculostomy? a. Clear cerebral spinal fluid (CSF) b. Nuchal rigidity c. Hypothermia d. Tachycardia 20. The nurse is planning care for a client who is newly diagnosed with human immunodeficiency virus (HIV). Which of the following prescribed prophylactic measures should the nurse include in the client’s plan of care? Select all that apply. a. Influenza vaccine b. Varicella zoster immune globulin, human c. Trimethoprim-sulfamethoxazole d. Pneumococcal Vaccine e. Hepatitis B vaccine 21. The nurse is caring for a client who is receiving prescribed heparin 5,000 units/hr. The label on the bag reads 25,000 units/500 ml. How many mL per hour should the client be receiving? 22. The nurse has assessed a client, who hit their head during a fall, using the Glasgow Coma Scale (GCS) and calculated a score of 6. Which of the following actions would be appropriate for the nurse to take in addition to notifying the health care provider of the GCS score? a. Prepare to administer intravenous epinephrine b. Ask the client’s family about their wishes regarding donation of the client’s organs. c. Place the client’s prescribed intravenous infusion of mannitol on hold. d. Contact the anesthesiology department. 23. The nurse is caring for a client who fell at home and is diagnosed with right hip fracture. Which of the following would be most important for the nurse to assess? a. Internal or external rotation of the affected extremity b. Pedal pulses and capillary refill of the affected extremity c. Right leg shortening d. Ecchymosis of the affected area 24. The nurse has taught a client about newly prescribed clopidogrel. Which of the following statements, by the client, would indicate a correct understanding of the teaching? a. “I will need to notify my dentist before any appointments that I am taking clopidogrel.” b. “I should take ibuprofen instead of acetaminophen for a headache, while I am taking clopidogrel.” c. “This medication does not require blood level monitoring.” d. “This medication will help reduce my risk of bleeding.” 25. The nurse in the emergency department has received a client exhibiting manifestations of a stroke, which the client’s spouse says began 90 minutes ago. The client’s CT scan confirms stroke and ruled out intracranial hemorrhage. Which of the following actions should the nurse take first? a. Notify the client’s family or next of kin b. Obtain informed consent for surgery c. Arrange swallow evaluation by a speech therapist d. Establish intravenous access 26. The nurse on the neurological unit is caring for a client who sustained a basilar skull fracture 6 hours ago. The client is awake and oriented. Which of the following remarks by the client should be a priority for the nurse to follow up? a. “The nursing assistant told me I have bruises behind my ears.” b. The pain medicine has decreased my headache.” c. “I have felt a little dizzy since the accident.” d. “I would like some tissues for my runny nose.” 27. The nurse is caring for a client with increased intracranial pressure (ICP). The nurse observes the client’s urine output from the indwelling urethral catheter to be 1,500 ml for the last 2 hours. Which of the following should the nurse suspect the client is experiencing? a. Cushing’s syndrome b. Syndrome of inappropriate antidiuretic hormone c. Diabetes insipidus (DI) d. Adrenal crisis 28. The nurse on the neurosurgical unit is receiving a client who has a history of transient ischemic attacks and had and intracranial stent placed 30 minutes ago. Which of the following would be a standard post-procedure nursing measure after intracranial stent placement? a. Assessing the client for Battle’s sign b. Keeping the client’s leg straight c. Maintaining the client in a semi-fowler’s position d. Administering tPA to the client 29. The nurse is caring for client who has just been diagnosed with hemorrhagic stroke. The client’s family is asking the nurse for information about the client’s condition. Which of the following statements by the nurse would be appropriate? a. “Strokes occur because of plaque build-up in the arteries of the brain.” b. “The priority is to get your family member to stop bleeding.” c. ‘We might need consent for immediate surgical intervention.” d. “We will know if there is any physical function impairment in a few days.” 30. The nurse is caring for a client with increased intracranial pressure (ICP). The client has a nursing diagnosis of ineffective cerebral tissue perfusion. Which of the following would be an expected outcome for this client? a. Obeys commands with appropriate motors responses b. Copes with sensory deprivation c. Registers normal body temperature d. Maintains appropriate fluid balance 31. The nurse on the stroke team has received a client who is exhibiting signs of stoke and is being transported for a CT scan of the brain. Which of the following information would be the priority for the nurse to try to obtain? a. A list of the client’s food and medication allergies b. Whether the client has a cardiac history c. The client’s blood type d. Time the client’s signs and symptoms began 32. The nurse on the neurological care unit is planning a staff education about condition that would require intracranial pressure monitoring with a ventriculostomy. Which of the following conditions should the nurse include in the conference? Select all that apply. a. Carotid stenosis b. Epilepsy c. Encephalitis d. Subdural hematoma e. Brain tumor 33. The nurse is caring for client who has aphasia following a stroke. Which of the following would facilitate communication with the client? Select all that apply. a. Speak to the client using a louder tone than usual b. Have the client assign a family member to speak on behalf of the client c. Decrease environmental stimuli before communicating with the client. d. Try to anticipate the last part of the client’s sentence and fill it in for the client. e. Ask questions the client can answer with one word. 34. The nurse on the neurological care unit has received a client who has been diagnosed with subarachnoid hemorrhage. The nurse should prepare the client for which of the following potential treatments? Select all that apply. a. Ventriculostomy insertion b. IV antihypertensive administration c. IV heparin administration d. IV tPA administration e. Surgical clipping 35. The nurse is caring for a client who has been diagnosed with acute subdural hematoma after falling at home. Which of the following findings should indicate to the nurse that the client is experiencing a complication? a. Narrowing pulse pressure b. Unilateral pupil dilation c. Ipsilateral hemiparesis d. Nuchal rigidity 36. The nurse has taught an education conference about antibiotics being prescribed for clients with skull fractures who have rhinorrhea and otorrhea. Which of the following statements by a nurse would indicate a correct understanding of the conference? a. “Antibiotics prevent infection when the protective membrane around the brain is disrupted.” b. “Preventative treatment is indicated for skull fracture to decrease bone infection.” c. “Antibiotics use with this type of injury can mask symptoms of complications.” d. “Clients with head injury are prone to pneumonia because they are on bed rest.” 37. While performing a genital assessment on a 26-yr. old male client, the nurse notices multiple soft, moist, painless papules in the shapes of cauliflower-like patches scattered across the shaft of the penis. Which of the following should the nurse suspect the client is experiencing? a. Syphilitic chancres b. Genital warts c. Genital herpes d. Gonococcal infection 38. The nurse in the emergency department receives a client who was transported from a prison with high fever, severe headache, and a non-blanchable rash on the trunk and lower extremities. Which of the following actions would be appropriate for the nurse to take, while the staff works to confirm a diagnosis? a. Keep the room well-lit to reduce hallucinations b. Advise the client and nursing assistant to keep the head of the bed flat c. Perform scheduled oropharyngeal suctioning every hour. d. Hang a respiratory isolation sign on the door of the client’s room. 39. The nurse on the neurological unit is caring for a client who had a traumatic brain injury. The client’s Glascow Coma Score has changed from 10 to 9, and the client is snoring. Which of the following actions would be appropriate for the nurse to take? a. Position the client’s neck in flexion b. Request a prescription for a benzodiazepine c. Suction the client’s oral secretions d. Place the client in Trendelenburg. 40. The nurse caring for a client who has hemiparesis following a right hemispheric stroke has taught the client’s spouse ways to help care for the client. Which of the following actions by the client’s spouse would require the nurse to intervene? a. Instructing the client to reach the left hand to the far wheelchair arm during transfer from the bed b. Keeping a high-top sneaker on the client’s left foot while the client rests in bed c. Placing a food on the right side of the client’s mouth d. Positioning a hand cone in the client’s left hand 41. The nurse on the mental health unit, is caring for a client who has had several verbal outbursts, is pacing around the unit and is at risk for assaultive behavior. Which of the following statements by the nurse would be most appropriate? a. “I am going to check your blood pressure because I think you are anxious.” b. “Please take a time-out in your room.” c. “Try not to get agitated, everything is safe here.” d. “If you do not follow the rules, you will be put in seclusion.” 42. The nurse on the neurological care unit is assessing a client who has a Glasgow Coma Scale of 3. Which of the following findings is consistent with a GCS score of 3? a. Conversant but confused b. Flexion withdrawal from painful stimulus c. Sluggish pupillary and corneal reflexes d. Urinary and fecal incontinence 43. The nurse is providing discharge teaching about post-concussion syndrome for a client and the client’s family. The nurse should include in the teaching that the client might experience which of the following? Select all that apply. a. Hemiplegia b. Headache c. Dysphagia d. Personality changes e. Decreased short-term memory f. Aphasia 44. The nurse is caring for a client immediately after receiving a craniotomy with an incision over the middle fossa and notes the client is in a supine position? Which of the following actions would be most appropriate for the nurse to take? a. Elevate the head of the bed 30 to 45 degrees and the complete an incident report. b. Keep the client in the supine position for one hour and then elevate the head of the bed to 10 to 15 degrees. c. Assess the client’s dressing and implement postoperative prescriptions. d. Continue to monitor the client’s neurological status in the supine position. 45. The nurse is planning care for a client with moderate rheumatoid arthritis (RA). Which of the following nonpharmacologic interventions should the nurse include in the client’s plan of care? Select all that apply. a. Select clothing that contains hook and loop (Velcro) fasteners b. Apply moist heat to joints c. Avoid performing range of motion (ROM) exercises d. Apply splints to inflamed joints e. Use assistive devices at all times 46. The nurse is caring for a client who had a total knee replacement (TKR) and has been placed in a continuous passive motion (CPM) device. The client asks, “What is the purpose of this machine?” The nurse should explain the purpose by telling the client which of the following? a. “The machine prevents emboli from occurring while you are in bed.” b. “The machine is used to prevent scarring of the incision site and keep elevated.” c. “The machine helps promote mobility until you can begin moving your knee independently.” d. “The machine helps to decrease discomfort while your activity level is diminished.” 47. The nurse is caring for a client who requires prescribed mannitol 2g/kg as 15% solution over 1 hour. The nurse has a 15% solution on hand and the client weighs 186 lbs. How many grams of medication should the nurse administer? Round your answer to the hundredth place. 22. The nurse has assessed a client, who hit their head during a fall, using the Glasgow Coma Scale (GCS) and calculated a score of 6. Which of the following actions would be appropriate for the nurse to take in addition to notifying the health care provider of the GCS score? a. Prepare to administer intravenous epinephrine b. Ask the client’s family about their wishes regarding donation of the client’s organs. c. Place the client’s prescribed intravenous infusion of mannitol on hold. d. Contact the anesthesiology department. 23. The nurse is caring for a client who fell at home and is diagnosed with right hip fracture. Which of the following would be most important for the nurse to assess? a. Internal or external rotation of the affected extremity b. Pedal pulses and capillary refill of the affected extremity c. Right leg shortening d. Ecchymosis of the affected area 24. The nurse has taught a client about newly prescribed clopidogrel. Which of the following statements, by the client, would indicate a correct understanding of the teaching? a. “I will need to notify my dentist before any appointments that I am taking clopidogrel.” b. “I should take ibuprofen instead of acetaminophen for a headache, while I am taking clopidogrel.” c. “This medication does not require blood level monitoring.” d. “This medication will help reduce my risk of bleeding.” 25. The nurse in the emergency department has received a client exhibiting manifestations of a stroke, which the client’s spouse says began 90 minutes ago. The client’s CT scan confirms stroke and ruled out intracranial hemorrhage. Which of the following actions should the nurse take first? a. Notify the client’s family or next of kin b. Obtain informed consent for surgery c. Arrange swallow evaluation by a speech therapist d. Establish intravenous access 26. The nurse on the neurological unit is caring for a client who sustained a basilar skull fracture 6 hours ago. The client is awake and oriented. Which of the following remarks by the client should be a priority for the nurse to follow up? a. “The nursing assistant told me I have bruises behind my ears.” b. The pain medicine has decreased my headache.” c. “I have felt a little dizzy since the accident.” d. “I would like some tissues for my runny nose.” 27. The nurse is caring for a client with increased intracranial pressure (ICP). The nurse observes the client’s urine output from the indwelling urethral catheter to be 1,500 ml for the last 2 hours. Which of the following should the nurse suspect the client is experiencing? a. Cushing’s syndrome b. Syndrome of inappropriate antidiuretic hormone c. Diabetes insipidus (DI) d. Adrenal crisis 28. The nurse on the neurosurgical unit is receiving a client who has a history of transient ischemic attacks and had and intracranial stent placed 30 minutes ago. Which of the following would be a standard post-procedure nursing measure after intracranial stent placement? a. Assessing the client for Battle’s sign b. Keeping the client’s leg straight c. Maintaining the client in a semi-fowler’s position d. Administering tPA to the client 29. The nurse is caring for client who has just been diagnosed with hemorrhagic stroke. The client’s family is asking the nurse for information about the client’s condition. Which of the following statements by the nurse would be appropriate? a. “Strokes occur because of plaque build-up in the arteries of the brain.” b. “The priority is to get your family member to stop bleeding.” c. ‘We might need consent for immediate surgical intervention.” d. “We will know if there is any physical function impairment in a few days.” 30. The nurse is caring for a client with increased intracranial pressure (ICP). The client has a nursing diagnosis of ineffective cerebral tissue perfusion. Which of the following would be an expected outcome for this client? a. Obeys commands with appropriate motors responses b. Copes with sensory deprivation c. Registers normal body temperature d. Maintains appropriate fluid balance 31. The nurse on the stroke team has received a client who is exhibiting signs of stoke and is being transported for a CT scan of the brain. Which of the following information would be the priority for the nurse to try to obtain? a. A list of the client’s food and medication allergies b. Whether the client has a cardiac history c. The client’s blood type d. Time the client’s signs and symptoms began 32. The nurse on the neurological care unit is planning a staff education about condition that would require intracranial pressure monitoring with a ventriculostomy. Which of the following conditions should the nurse include in the conference? Select all that apply. a. Carotid stenosis b. Epilepsy c. Encephalitis d. Subdural hematoma e. Brain tumor 33. The nurse is caring for client who has aphasia following a stroke. Which of the following would facilitate communication with the client? Select all that apply. a. Speak to the client using a louder tone than usual b. Have the client assign a family member to speak on behalf of the client c. Decrease environmental stimuli before communicating with the client. d. Try to anticipate the last part of the client’s sentence and fill it in for the client. e. Ask questions the client can answer with one word. 34. The nurse on the neurological care unit has received a client who has been diagnosed with subarachnoid hemorrhage. The nurse should prepare the client for which of the following potential treatments? Select all that apply. a. Ventriculostomy insertion b. IV antihypertensive administration c. IV heparin administration d. IV tPA administration e. Surgical clipping 35. The nurse is caring for a client who has been diagnosed with acute subdural hematoma after falling at home. Which of the following findings should indicate to the nurse that the client is experiencing a complication? a. Narrowing pulse pressure b. Unilateral pupil dilation c. Ipsilateral hemiparesis d. Nuchal rigidity 36. The nurse has taught an education conference about antibiotics being prescribed for clients with skull fractures who have rhinorrhea and otorrhea. Which of the following statements by a nurse would indicate a correct understanding of the conference? a. “Antibiotics prevent infection when the protective membrane around the brain is disrupted.” b. “Preventative treatment is indicated for skull fracture to decrease bone infection.” c. “Antibiotics use with this type of injury can mask symptoms of complications.” d. “Clients with head injury are prone to pneumonia because they are on bed rest.” 37. While performing a genital assessment on a 26-yr. old male client, the nurse notices multiple soft, moist, painless papules in the shapes of cauliflower-like patches scattered across the shaft of the penis. Which of the following should the nurse suspect the client is experiencing? a. Syphilitic chancres b. Genital warts c. Genital herpes d. Gonococcal infection 38. The nurse in the emergency department receives a client who was transported from a prison with high fever, severe headache, and a non-blanchable rash on the trunk and lower extremities. Which of the following actions would be appropriate for the nurse to take, while the staff works to confirm a diagnosis? a. Keep the room well-lit to reduce hallucinations b. Advise the client and nursing assistant to keep the head of the bed flat c. Perform scheduled oropharyngeal suctioning every hour. d. Hang a respiratory isolation sign on the door of the client’s room. 39. The nurse on the neurological unit is caring for a client who had a traumatic brain injury. The client’s Glascow Coma Score has changed from 10 to 9, and the client is snoring. Which of the following actions would be appropriate for the nurse to take? a. Position the client’s neck in flexion b. Request a prescription for a benzodiazepine c. Suction the client’s oral secretions d. Place the client in Trendelenburg. 40. The nurse caring for a client who has hemiparesis following a right hemispheric stroke has taught the client’s spouse ways to help care for the client. Which of the following actions by the client’s spouse would require the nurse to intervene? a. Instructing the client to reach the left hand to the far wheelchair arm during transfer from the bed b. Keeping a high-top sneaker on the client’s left foot while the client rests in bed c. Placing a food on the right side of the client’s mouth d. Positioning a hand cone in the client’s left hand 41. The nurse on the mental health unit, is caring for a client who has had several verbal outbursts, is pacing around the unit and is at risk for assaultive behavior. Which of the following statements by the nurse would be most appropriate? a. “I am going to check your blood pressure because I think you are anxious.” b. “Please take a time-out in your room.” c. “Try not to get agitated, everything is safe here.” d. “If you do not follow the rules, you will be put in seclusion.” 42. The nurse on the neurological care unit is assessing a client who has a Glasgow Coma Scale of 3. Which of the following findings is consistent with a GCS score of 3? a. Conversant but confused b. Flexion withdrawal from painful stimulus c. Sluggish pupillary and corneal reflexes d. Urinary and fecal incontinence 43. The nurse is providing discharge teaching about post-concussion syndrome for a client and the client’s family. The nurse should include in the teaching that the client might experience which of the following? Select all that apply. a. Hemiplegia b. Headache c. Dysphagia d. Personality changes e. Decreased short-term memory f. Aphasia 44. The nurse is caring for a client immediately after receiving a craniotomy with an incision over the middle fossa and notes the client is in a supine position? Which of the following actions would be most appropriate for the nurse to take? a. Elevate the head of the bed 30 to 45 degrees and the complete an incident report. b. Keep the client in the supine position for one hour and then elevate the head of the bed to 10 to 15 degrees. c. Assess the client’s dressing and implement postoperative prescriptions. d. Continue to monitor the client’s neurological status in the supine position. 45. The nurse is planning care for a client with moderate rheumatoid arthritis (RA). Which of the following nonpharmacologic interventions should the nurse include in the client’s plan of care? Select all that apply. a. Select clothing that contains hook and loop (Velcro) fasteners b. Apply moist heat to joints c. Avoid performing range of motion (ROM) exercises d. Apply splints to inflamed joints e. Use assistive devices at all times 46. The nurse is caring for a client who had a total knee replacement (TKR) and has been placed in a continuous passive motion (CPM) device. The client asks, “What is the purpose of this machine?” The nurse should explain the purpose by telling the client which of the following? a. “The machine prevents emboli from occurring while you are in bed.” b. “The machine is used to prevent scarring of the incision site and keep elevated.” c. “The machine helps promote mobility until you can begin moving your knee independently.” d. “The machine helps to decrease discomfort while your activity level is diminished.” 47. The nurse is caring for a client who requires prescribed mannitol 2g/kg as 15% solution over 1 hour. The nurse has a 15% solution on hand and the client weighs 186 lbs. How many grams of medication should the nurse administer? Round your answer to the hundredth place. 22. The nurse has assessed a client, who hit their head during a fall, using the Glasgow Coma Scale (GCS) and calculated a score of 6. Which of the following actions would be appropriate for the nurse to take in addition to notifying the health care provider of the GCS score? a. Prepare to administer intravenous epinephrine b. Ask the client’s family about their wishes regarding donation of the client’s organs. c. Place the client’s prescribed intravenous infusion of mannitol on hold. d. Contact the anesthesiology department. 23. The nurse is caring for a client who fell at home and is diagnosed with right hip fracture. Which of the following would be most important for the nurse to assess? a. Internal or external rotation of the affected extremity b. Pedal pulses and capillary refill of the affected extremity c. Right leg shortening d. Ecchymosis of the affected area 24. The nurse has taught a client about newly prescribed clopidogrel. Which of the following statements, by the client, would indicate a correct understanding of the teaching? a. “I will need to notify my dentist before any appointments that I am taking clopidogrel.” b. “I should take ibuprofen instead of acetaminophen for a headache, while I am taking clopidogrel.” c. “This medication does not require blood level monitoring.” d. “This medication will help reduce my risk of bleeding.” 25. The nurse in the emergency department has received a client exhibiting manifestations of a stroke, which the client’s spouse says began 90 minutes ago. The client’s CT scan confirms stroke and ruled out intracranial hemorrhage. Which of the following actions should the nurse take first? a. Notify the client’s family or next of kin b. Obtain informed consent for surgery c. Arrange swallow evaluation by a speech therapist d. Establish intravenous access 26. The nurse on the neurological unit is caring for a client who sustained a basilar skull fracture 6 hours ago. The client is awake and oriented. Which of the following remarks by the client should be a priority for the nurse to follow up? a. “The nursing assistant told me I have bruises behind my ears.” b. The pain medicine has decreased my headache.” c. “I have felt a little dizzy since the accident.” d. “I would like some tissues for my runny nose.” 27. The nurse is caring for a client with increased intracranial pressure (ICP). The nurse observes the client’s urine output from the indwelling urethral catheter to be 1,500 ml for the last 2 hours. Which of the following should the nurse suspect the client is experiencing? a. Cushing’s syndrome b. Syndrome of inappropriate antidiuretic hormone c. Diabetes insipidus (DI) d. Adrenal crisis 28. The nurse on the neurosurgical unit is receiving a client who has a history of transient ischemic attacks and had and intracranial stent placed 30 minutes ago. Which of the following would be a standard post-procedure nursing measure after intracranial stent placement? a. Assessing the client for Battle’s sign b. Keeping the client’s leg straight c. Maintaining the client in a semi-fowler’s position d. Administering tPA to the client 29. The nurse is caring for client who has just been diagnosed with hemorrhagic stroke. The client’s family is asking the nurse for information about the client’s condition. Which of the following statements by the nurse would be appropriate? a. “Strokes occur because of plaque build-up in the arteries of the brain.” b. “The priority is to get your family member to stop bleeding.” c. ‘We might need consent for immediate surgical intervention.” d. “We will know if there is any physical function impairment in a few days.” 30. The nurse is caring for a client with increased intracranial pressure (ICP). The client has a nursing diagnosis of ineffective cerebral tissue perfusion. Which of the following would be an expected outcome for this client? a. Obeys commands with appropriate motors responses b. Copes with sensory deprivation c. Registers normal body temperature d. Maintains appropriate fluid balance 31. The nurse on the stroke team has received a client who is exhibiting signs of stoke and is being transported for a CT scan of the brain. Which of the following information would be the priority for the nurse to try to obtain? a. A list of the client’s food and medication allergies b. Whether the client has a cardiac history c. The client’s blood type d. Time the client’s signs and symptoms began 32. The nurse on the neurological care unit is planning a staff education about condition that would require intracranial pressure monitoring with a ventriculostomy. Which of the following conditions should the nurse include in the conference? Select all that apply. a. Carotid stenosis b. Epilepsy c. Encephalitis d. Subdural hematoma e. Brain tumor 33. The nurse is caring for client who has aphasia following a stroke. Which of the following would facilitate communication with the client? Select all that apply. a. Speak to the client using a louder tone than usual b. Have the client assign a family member to speak on behalf of the client c. Decrease environmental stimuli before communicating with the client. d. Try to anticipate the last part of the client’s sentence and fill it in for the client. e. Ask questions the client can answer with one word. 34. The nurse on the neurological care unit has received a client who has been diagnosed with subarachnoid hemorrhage. The nurse should prepare the client for which of the following potential treatments? Select all that apply. a. Ventriculostomy insertion b. IV antihypertensive administration c. IV heparin administration d. IV tPA administration e. Surgical clipping 35. The nurse is caring for a client who has been diagnosed with acute subdural hematoma after falling at home. Which of the following findings should indicate to the nurse that the client is experiencing a complication? a. Narrowing pulse pressure b. Unilateral pupil dilation c. Ipsilateral hemiparesis d. Nuchal rigidity 36. The nurse has taught an education conference about antibiotics being prescribed for clients with skull fractures who have rhinorrhea and otorrhea. Which of the following statements by a nurse would indicate a correct understanding of the conference? a. “Antibiotics prevent infection when the protective membrane around the brain is disrupted.” b. “Preventative treatment is indicated for skull fracture to decrease bone infection.” c. “Antibiotics use with this type of injury can mask symptoms of complications.” d. “Clients with head injury are prone to pneumonia because they are on bed rest.” 37. While performing a genital assessment on a 26-yr. old male client, the nurse notices multiple soft, moist, painless papules in the shapes of cauliflower-like patches scattered across the shaft of the penis. Which of the following should the nurse suspect the client is experiencing? a. Syphilitic chancres b. Genital warts c. Genital herpes d. Gonococcal infection 38. The nurse in the emergency department receives a client who was transported from a prison with high fever, severe headache, and a non-blanchable rash on the trunk and lower extremities. Which of the following actions would be appropriate for the nurse to take, while the staff works to confirm a diagnosis? a. Keep the room well-lit to reduce hallucinations b. Advise the client and nursing assistant to keep the head of the bed flat c. Perform scheduled oropharyngeal suctioning every hour. d. Hang a respiratory isolation sign on the door of the client’s room. 39. The nurse on the neurological unit is caring for a client who had a traumatic brain injury. The client’s Glascow Coma Score has changed from 10 to 9, and the client is snoring. Which of the following actions would be appropriate for the nurse to take? a. Position the client’s neck in flexion b. Request a prescription for a benzodiazepine c. Suction the client’s oral secretions d. Place the client in Trendelenburg. 40. The nurse caring for a client who has hemiparesis following a right hemispheric stroke has taught the client’s spouse ways to help care for the client. Which of the following actions by the client’s spouse would require the nurse to intervene? a. Instructing the client to reach the left hand to the far wheelchair arm during transfer from the bed b. Keeping a high-top sneaker on the client’s left foot while the client rests in bed c. Placing a food on the right side of the client’s mouth d. Positioning a hand cone in the client’s left hand 41. The nurse on the mental health unit, is caring for a client who has had several verbal outbursts, is pacing around the unit and is at risk for assaultive behavior. Which of the following statements by the nurse would be most appropriate? a. “I am going to check your blood pressure because I think you are anxious.” b. “Please take a time-out in your room.” c. “Try not to get agitated, everything is safe here.” d. “If you do not follow the rules, you will be put in seclusion.” 42. The nurse on the neurological care unit is assessing a client who has a Glasgow Coma Scale of 3. Which of the following findings is consistent with a GCS score of 3? a. Conversant but confused b. Flexion withdrawal from painful stimulus c. Sluggish pupillary and corneal reflexes d. Urinary and fecal incontinence 43. The nurse is providing discharge teaching about post-concussion syndrome for a client and the client’s family. The nurse should include in the teaching that the client might experience which of the following? Select all that apply. a. Hemiplegia b. Headache c. Dysphagia d. Personality changes e. Decreased short-term memory f. Aphasia 44. The nurse is caring for a client immediately after receiving a craniotomy with an incision over the middle fossa and notes the client is in a supine position? Which of the following actions would be most appropriate for the nurse to take? a. Elevate the head of the bed 30 to 45 degrees and the complete an incident report. b. Keep the client in the supine position for one hour and then elevate the head of the bed to 10 to 15 degrees. c. Assess the client’s dressing and implement postoperative prescriptions. d. Continue to monitor the client’s neurological status in the supine position. 45. The nurse is planning care for a client with moderate rheumatoid arthritis (RA). Which of the following nonpharmacologic interventions should the nurse include in the client’s plan of care? Select all that apply. a. Select clothing that contains hook and loop (Velcro) fasteners b. Apply moist heat to joints c. Avoid performing range of motion (ROM) exercises d. Apply splints to inflamed joints e. Use assistive devices at all times 46. The nurse is caring for a client who had a total knee replacement (TKR) and has been placed in a continuous passive motion (CPM) device. The client asks, “What is the purpose of this machine?” The nurse should explain the purpose by telling the client which of the following? a. “The machine prevents emboli from occurring while you are in bed.” b. “The machine is used to prevent scarring of the incision site and keep elevated.” c. “The machine helps promote mobility until you can begin moving your knee independently.” d. “The machine helps to decrease discomfort while your activity level is diminished.” 47. The nurse is caring for a client who requires prescribed mannitol 2g/kg as 15% solution over 1 hour. The nurse has a 15% solution on hand and the client weighs 186 lbs. How many grams of medication should the nurse administer? Round your answer to the hundredth place. 48. The nurse is assessing a client who fell in the hallway and notes the client is exhibiting an altered level of consciousness (LOC) and Battle’s sign is present. Which of the following actions would be a priority for the nurse to take? a. Stabilize the client’s neck b. Insert a peripheral intravenous catheter c. Prepare for the client to be intubated d. Administer oxygen 49. The nurse on the neurological unit is preparing to receive a client from the emergency department who had an ischemic stroke. The nurse demonstrates appropriate anticipation of the client’s potential needs by gathering which of the following? Select all that apply. a. NPO door sign b. Lumbar puncture supplies c. Bedpan d. Siderail pads e. Soft wrist restraints f. Equipment for suctioning 50. The nurse on the stroke team is working with colleagues to stabilize a client who has just been brought to the hospital with stroke symptoms. Which of the following actions by the unlicensed assistive personnel (UAP) would require intervention by the nurse? a. Assisting the client to take sips of water b. Performing a finger stick check the client’s blood glucose level c. Removing the client’s dentures d. Placing pads on the siderails of the client’s bed 51. The nurse is changing the descending colostomy for a client with a history of Crohn’s disease. Which of the following findings would be a priority for the nurse to follow up? a. Slight odor noted with removal of appliance b. Formed, brown stool c. Stoma that is dark, purple-blue and dry d. Erythematous, intact skin around the stoma 52. The nurse is observing family members care for a client who has multiple deficits following a stroke 2 weeks ago. The nurse must intervene if a family member is observed doing which of the following? a. Massaging a reddened area on the client’s sacrum b. Putting a thickening agent in the client’s coffee c. Assisting with peri care after using the commode d. Asking the client questions that require only one-word answers 53. The nurse is caring for a client who has a subdural hematoma following a traumatic head injury. The nurse notes systolic hypertension with a widening pulse pressure and bradycardia. Which of the following actions would be appropriate for the nurse to take after notifying the health care provider? a. Perform suctioning through the client’s endotracheal tube b. Gather supplies for administration of intravenous 0.45% sodium chloride c. Prepare the client for emergency surgery d. Place the client in Trendelenburg position 54. The nurse is providing information for the family of a client who had a transient ischemic attack and is scheduled for a carotid endarterectomy. Which of the following information would be appropriate for the nurse to give the family? a. “Blocked arteries in the brain are opened by using this removable stent system.” b. “Surgical clips are placed on arteries that have burst and caused bleeding in the brain.” c. “The left atrial appendage will be occluded to decrease the risk of future strokes.” d. “Plaque is removed from an artery that supplies blood to the brain.” 55. The nurse on the neurological care unit has received health care provider prescriptions for assigned clients. The nurse should contact the health care provider and question which of the following prescriptions? a. Morphine sulfate for a client with a skull fracture who has a Glasgow Coma Scale of 15 b. 0.45% sodium chloride for a client with increased intracranial pressure following traumatic brain injury c. Dexamethasone for a client with vasogenic edema secondary to brain tumor d. Lovastatin for a client who had an ischemic stroke 6 days ago CONTINUED......................DOWNLOAD FOR MORE REVISION TO BEST SCORES