Exam 6 Ch41

22問 • 2年前

問題一覧

1. A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. Currently the client’s neurologic examination is normal. About what drug would the nurse plan to teach the patient?

b. Clopidogrel

2. The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke?

c. Unilateral weakness during a TIA

3. The nurse is taking a history from a daughter about her father’s onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke?

d. Client has a long history of atrial fibrillation.

4. A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time?

a. Assess the client for hypoglycemia and hypoxia.

5. The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse’s teaching?

b. “I will remind the client frequently to not get out of bed without help.”

6. A nurse receives a hand-off report on a female client who had a left-sided stroke with homonymous hemianopsia. What action by the nurse is most appropriate for this client?

d. Remind the client to move her head from side to side to increase her visual field.

7. A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain?

d. Time of symptom onset

8. The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct about the administration of this drug?

d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy.

9. A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse’s first action?

b. Discontinue the infusion of the drug.

10. A client experiences impaired swallowing after a stroke and has worked with speech–language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met?

c. Has clear lung sounds on auscultation.

11. A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client’s nutritional needs. Which response by the nurse is appropriate?

a. “He is NPO until the speech–language pathologist performs a swallowing evaluation.”

12. A client is admitted with a diagnosis of cerebellar stroke. What intervention is most appropriate to include on the client’s plan of care?

a. Ambulate only with a gait belt.

13. A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk for a stroke?

a. A 27-year-old heavy-cocaine user.

14. The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client?

d. Decreased level of consciousness

15. A client is admitted with a traumatic brain injury. What is the nurse’s priority assessment?

c. Airway and breathing assessment

16. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient’s spouse is very frustrated, stating that the patient’s personality has changed and the situation is very difficult. What response by the nurse is most appropriate?

a. Explain that personality changes are common following brain injuries.

17. The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first?

d. Client who has a temperature of 102° F (38.9° C)

18. A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate?

d. Contact the local organ procurement organization as soon as possible.

19. After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes, acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first?

b. Assess the client’s serum sodium level.

20. A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process?

a. Cardiac dysrhythmias

21. A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client?

c. Mannitol

22. A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct?

a. “Increased pressure from the tumor can cause seizures.”

NUR 170 exam 4

V Farris · 50問 · 2年前

NUR 170 exam 4