August 7, 2021

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August 7, 2021 - Set B

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1. A 30-year-old client is admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? *

1 point

A. Bladder distension

B. Neurologic deficit

C. Pulse oximetry readings

D. The client’s feelings about the injury

2. An 82-year-old patient is experiencing confusion and forgetfulness. He is diagnosed with vascular dementia. The family asks the nurse for the information about the cause of this disorder. Which of the following statements made by the nurse is correct? *

1 point

A. “The cause of this type of dementia is unknown.”

B. “Vascular dementia is a result of many small strokes damaging areas of the brain.”

C. “Vascular dementia is caused by viral infection.”

D. “The dementia symptoms are caused by the medications he is taking.”

3. Which of the following diets would be the least likely to lead to aspiration in a client who had a stroke with residual dysphagia? *

1 point

A. Clear liquid

B. Full liquid

C. Mechanical soft

D. Thickened liquid

4. A client comes to the emergency department after hitting his head in a motor vehicle accident. He’s alert and oriented. Which of the following nursing interventions should be done first? *

1 point

A. Assess full range of motion (ROM) to determine the extent of injuries.

B. Call for an immediate chest X-ray

C. Immobilize the client’s head and neck.

D. Open the airway with the head-tilt chin-lift maneuver.

5. The nurse is caring for an adult client who was admitted unconscious. The initial assessment utilized the Glasgow Coma Scale. The nurse knows that the Glasgow Coma - P Scale is a systematic neurologic assessment tool that evaluates all of the following: *

1 point

A. All of the above

B. 1, 2 and 3 only

C. 2 and 3 only

D. 4 only

6. A client is having problems controlling her seizures and is referred to have electroencephalography (EEG) performed. Prior to the test, the nurse practitioner explains to the client that: *

1 point

A. This test will cause some discomfort and she will be given a sedative before the test

B. It will be important for her to take her regular dose of fluoxetine (prozac) and phenytoin (dilantin) prior to the test

C. The procedure is painless and she will not be in any discomfort or experience electrical shock during the procedure

D. After the test, she will be on bed rest for 8 hours and will be given full liquids for 12 hours

7. A client is admitted to a rural clinic after a diving accident. The nurse practitioner suspects a spinal cord injury at cervical level 5 (C5). While awaiting emergency transport services, the nurse practitioner assesses for the development of complications by: *

1 point

A. Checking for voluntary movement of extremities and sensation below the level of injury

B. Assessing breath sounds and evaluating movement of diaphragm with respirations

C. Maintaining cervical flexion to facilitate an airway until cervical traction is initiated

D. Beginning neurologic checks with careful documentation of location of pain sensations

8. A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which of the following assessment findings indicates to the nurse that the problem is occurring? *

1 point

A. Knee jerk reaction is absent bilaterally

B. The client complains of headache, and the blood pressure is elevated.

C. 100 ml of residual urine remains after the client voids

D. Pupil responses are brisk bilaterally

9. The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? *

1 point

A. extent of intracranial bleeding

B. activity of the brain

C. sites of brain injury

D. percent of functional brain tissue

10. The primary treatment of autonomic dysreflexia is: *

1 point

A. Analgesics

B. Antihypertensive drugs

C. Removal of the noxious stimuli

D. All of the above

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