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30 Cards in this Set
- Front
- Back
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When assessing a client who reports mastoiditis, it is best for the nurse to use which of the following techniques? -palpation -inspection -otoscopic examination -the Weber test |
Palpation |
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A nurse is admitting a female client to have surgery to repair an unruptured arteriovenous malformation (AVM). The AVM was discovered after the client reported recurrent headaches and MRI was completed. Which of the following factors is helpful in regard to the nurse anticipating the client's other neurological manifestation? -Baseline visual acuity -Age of the client -Duration of the manifestations -Location of the AVM |
Location of the AVM |
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In which of the following positions should a nurse place a client following a craniotomy for evacuation of a subdural hematoma of the frontal lobe? -supine -prone -semi-fowlers -Sims |
semi-fowlers |
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A nurse understands that a client with a seizure disorder, who frequently experiences an aura is describing a -sensory warning that a seizure is imminent -continuous seizure state in which seizures occur in rapid succession -period of sleepiness following the seizure, during which arousal is difficult -brief loss of consciousness accompanied by staring |
sensory warning that a seizure is imminent |
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Which of the following statements, made by a client who has an intraocular lens implant this morning, should indicate to a nurse a proper understanding of discharge instructions? -"I will sleep in my recliner chair tonight." -"I will avoid bending over or coughing" -"I will follow a low-salt and caffeine-restricted diet" -"I will report any signs of photophobia to my physician." |
"I will avoid bending over or coughing" |
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A nurse is caring for a client with Guillain-Barre syndrome. Upon assessment, the nurse should anticipate that the client will exhibit which of the following? -Tonic-clonic seizures -Complaints of a severe headache and nausea -Weakness of the lower extremities -Decreased level of consciousness |
Weakness of the lower extremities |
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A nurse is caring for a client who is postoperative following a craniotomy to evacuate a subdural hematoma. The nurse notes the client's urine output is greater each hour than the previous hour: from 1800-1900, the urine output was 200 ml, from 1900-2000, it was 400 ml and from 2000-2100, it was 600 mL. The nurse informs the surgeon and anticipates that the laboratory value that will be prescribed at this time is -blood urea nitrogen -blood sugar -urine ketones -specific gravity |
Specific gravity |
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A bolus of mannitol (Osmitrol) is ordered for a client with a closed-head injury showing manifestations of increasing intracranial pressure. Prior to admistration, assessment shows: urine output 40 ml/hr, apical heart rate 88/min, and the pupils equal and reactive. The client is sleepy but easily aroused. After administering mannitol to the client, which of the following should indicate to the nurse that the medication is having the desired effect? -Urine output is 100 ml/hr -Pupils are dilated -Heart rate is 62/min -Client is difficult to rouse |
Urine output is 100 ml/hr |
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A nurse explains to a family of a client recently diagnosed with amyotrophic lateral sclerosis (ALS) that early manifestations typically include: -sensory dysfunction -weakness of the distal extremities -decreased cognitive functioning -altered temperature regulation |
weakness of the distal extremities |
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A nurse is talking to a client's spouse about degenerative complications associated with Parkinson's disease The highest priority topic for the nurse to talk to the spouse about is the risk for: -aspiration -emotional lability -impaired speech -self-care dependency |
Aspiration |
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A nurse is caring for a client who has sustained a high thoracic spinal cord injury following a diving accident. The nurse suspects that the client may be experiencing the complication of autonomic dysreflexia when the client exhibits -rhinorrhea -hypotension -tachycardia -a severe headache |
a severe headache |
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A client is transferred to a rehabilitation center 3 weeks following a cerebrovascular accident (CVA). The client's CVA involved the left side of the brain. Which of the following goals should the nurse anticipate including in the client's rehabilitation program? -Improving left-side motor function -Establishing the ability to communicate effectively -Learning to control impulsive behavior -Keeping the left side of the body safe |
Establishing the ability to communicate effectively |
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A client has been diagnosed with acute angle closure glaucoma. The nurse should expect the client to report -Showers of floaters -Flashes of light across the eye -Eye pain and blurred vision -Double vision |
Eye pain and blurred vision |
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A nurse performs a neurologic assessment on a client with a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement? -Dysphagia -Positive Babinski sign -Decreased deep tendon reflexes -Ataxia |
Dysphagia |
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A nurse in a clinic is providing teaching to an adolescent client who has been diagnosed with swimmer's ear, or external otitis, for the third time in 2 months. The nurse should instruct the client to -Dry the ear with a cotton swab after swimming -Instill hydrogen peroxide into the ear after swimming -Instill diluted alcohol into the ear after swimming -Dry the ear with a twisted paper towel wick after swimming |
Instill diluted alcohol into the ear after swimming |
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A nurse is caring for a client who was admitted secondary to transient ischemic attacks (TIA). The goal of therapy for the client is -reversal of disability -reduction of cerebral bleeding -reduction in cerebral edema -prevention of a cerebrovascular accident |
prevention of a cerebrovascular accident |
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A client with myopia asks the nurse about the possibility of Laser-Assisted In SIty Keratomileusis (LASIK) surgery. The nurse tells the client that which of the following is a commonly experienced side effect followin LASIK surgery? -Eyelid tics and twitching -Photosensitivity -Excessive tearing -Halos and glaring when driving at night |
Halos and glaring when driving at night |
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A nurse is educating a client who was just diagnosed with open angle glaucoma about the condition. Which of the following information should the nurse include in the teaching? (Select all that apply) -Do not take cold medications that contain pseudoephedrine -Expect impaired night vision -Glasses will be necessary to correct the accompanying presbyopia -Driving may be dangerous due to loss of peripheral vision -Laser surgery can help reestablish the flow of aqueous humor |
Do not take cold medications that contain pseudoephedrine Expect impaired night vision Driving may be dangerous due to loss of peripheral vision Laser surgery can help reestablish the flow of aqueous humor |
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A nurse is assessing an unconscious client has a rhythmical breathing pattern of increasing depth and a rate alternating with periods of apnea. The nurse should document that the client is having -ataxic respirations -Cheyne-Stokes respirations -Apneustic respirations -Kussmaul respirations |
Cheyne-stokes respirations |
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A client with diabetic retinopathy returns to the postoperative unit after laser photocoagulation surgery for subretinal hemorrhages. WHich of the following postoperative prescriptions from the provider should the nurse anticipate receiving? -Full liquid diet for 24 hr -Hydrocodone (Vicodin) 1 tablet PO every 4 hr PRN for pain -Bed rest in supine position -Docusate sodium (Colace) 100 mg PO twice daily |
Docusate sodium (Colace) 100 mg PO twice daily |
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A nurse is preparing to admit a client with myasthenia gravis who has been having increasingly frequent episodes of myastheic crises. Because of the client's history, which of the following equipment should the nurse ask the assistive personnel to place at the client's bedside? -Metered dose inhaler and peak flow meter -Incentive spirometer and cough pillow -Suction machine and suction catheters -External defribillator pads and telemetry monitor |
Suction machine and suction catheters |
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A nurse is assessing a client who is reporting a sore throat, pressure in the ear, decreased hearing, and mild dizziness. The client has been treating himself for a cold for 1 week. The nurse should expect an alteration of which of the following structures: -The temporomandibular joint -The inner ear -The external ear -The middle ear |
The middle ear |
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A client with Meniere's disease is hospitalized for recurring episodes caused by the disease. The nurse should anticipate documenting which of the following measure to help prevent exacerbations of the disease in the client's plan of care? -Avoid bearing down (Valsalva maneuver) -Increase fluid intake -Avoid sudden movements -Increase sodium intake |
Avoid sudden movements |
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A nurse is assessing a client who was just admitted to the hospital for observation following a closed-head injury. Which of the following is the most essential nursing assessment to detect early signs of a worsening condition? -Vital signs -Body posture -Level of Consciousness -Focal neurologic exam |
Level of consciousness |
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An unconscious client assumes a decerebrate posture in response to any noxious stimuli. When drawing a blood sample, the nurse should expect the client to -Rigidly extend all four extremities -Internally flex the arms and extend the legs -Tightly curl into a fetal position -Internally rotate the arms and legs |
Rigidly extend all four extremities |
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A client with a seizure disorder is being discharged. The client's family has many questions about what to do if the client has a seizure while at home. The nurse tells the family members that the first action to take in the event of a seizure is to... -Support and protect the client's head -Ease the client to the floor if standing or seated -Loosen constrictive clothing -Turn the client on his side |
Ease the client to the floor if standing or seated |
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A client with suspected cervical disc herniation is to undergo an MRI exam of the cervical vertebrae. The nurse assesses the client for any preexisting conditions that would contraindicate having an MRI. The nurse should notify the provider regarding the client's ability to have an MRI if the client has a history of -a titanium implant of the ankle -claustrophobia -a contrast dye allergy -an automatic internal defibrillatory placement |
An automatic internal defibrillator placement |
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A nurse obtains frequent vital signs on a client who is at risk for increased intracranial pressure. The previous vital signs were a blood pressure of 120/70 mm Hg and a hear tare of 92/min. The nurse should be concerned if the next set of vitals obtained are a -blood pressure of 160/65 mmHg and a heart rate of 68/min -blood pressure of 140/100 mmHg and a heart rate of 68/min -blood pressure of 150/100 mmHg and a heart rate of 112/min -blood pressure of 80/40 mmHg and a heart rate of 112/min |
Blood pressure of 160/65 mm Hg and a heart rate of 68/min |
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A client has undergone surgical repair via scleral buckling of a detached retina of the left eye with an injection of a gas bubble. The nurse should anticipate that the surgeon will prescibe the client to assume which postoperative position? -Semi-fowler's position while wearing shaded dilation glasses -Prone position with the operated eye up -Left lateral position with the eye shield on the left eye -Trendelenburg positon without a pillow |
Prone position with the operated eye up |
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A nurse is reading the results of a lumbar puncture (LP) performed on a client suspected of having bacterial meningitis. Which of the following findings should the nurse recognize as being consistent with this diagnosis? -Elevate glucose -Elevate protein -Presence of red blood cells -Presence of D-dimer |
Elevate protein |
