The nurse assesses a patient with pernicious anemia. Which finding would the nurse expect?

Tender, bleeding gums

A patient’s complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?

“Do you have any history of lung disease?”

The nurse is reviewing laboratory results and notes a patient’s activated partial thromboplastin time (aPTT) level is 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?

Heparin

The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered?

Hemoglobin level

The nurse examines the lymph nodes of a patient during a physical assessment. Which finding would be of most concern to the nurse?

A 2-cm nontender supraclavicular node

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?

Elevated reticulocyte count

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?

Avoid intramuscular injections.

The health care provider’s progress note for a patient states that the complete blood count (CBC) shows a “shift to the left.” Which assessment finding should the nurse expect?

Elevated temperature

The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take to prepare the patient for this procedure?

Assist the patient to a flat position.

A patient with pancytopenia of unknown origin is scheduled for diagnostic tests. The nurse will ensure a consent form was signed before which test?

Bone marrow biopsy

The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider?

White blood cell count 15,500/μL

16. Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider?

Assessment

BP 110/68
• Pulse 98 beats/min
• Brisk capillary refill
• Multiple ecchymoses on arms

Complete Blood Count

Hgb 10.6 g/dL
• Hct 30%
• WBC 5100/μL
• Platelets 19,500/μL

Patient History

Occasional aspirin use
• Abdominal pain x 1 week • Large, dark stool this morning

Platelet count

An adult male with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms?

Hemoglobin (Hgb) of 8.6 g/dL (86 g/L)

Which menu choice indicates that the patient understands the nurse’s recommendations about dietary choices for iron-deficiency anemia?

Omelet and whole wheat toast

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. Which nutrient supplement should the nurse plan to explain to the patient?

Folic acid

Which patient statement to the nurse indicates that the patient understands self-care for pernicious anemia?

I could choose nasal spray rather than injections of vitamin B12.”

Which is an appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia?

Encourage alternating rest and activity.

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?

“I should notify my health care provider if my stools turn black.”

Which potential complication should the nurse identify as a high risk for a patient admitted to the hospital with idiopathic aplastic anemia?

Infection

Which nursing intervention is important when providing care for a patient with sickle cell crisis?

Evaluating the effectiveness of opioid analgesics

Which statement by a patient indicates good understanding of the nurse’s teaching about preventing sickle cell crisis

“Risk for a crisis is decreased by having an annual influenza vaccination.”

Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis

Avoid exposure to crowds when possible.

The nurse observes scleral jaundice in a patient being admitted with hemolytic anemia. Which laboratory result the nurse should check?

Bilirubin level

A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/μL. Which action will the nurse include in the plan of care?

Discontinue the heparin infusion.

What action is expected by the nurse caring for a patient who has an acute exacerbation of polycythemia vera?

Monitor fluid intake and output.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura?

Avoid intramuscular (IM) injections.

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)?

Activated partial thromboplastin time

The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. Which action should the nurse take?

Immobilize the knee joint

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. Which laboratory value should the nurse monitor?

Bleeding time

A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. What should the nurse plan to explain to the patient?

Bone marrow biopsy

Which action will the admitting nurse include in the care plan for a patient who has neutropenia?

Check temperature every 4 hours.

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?

Absolute neutrophil count

A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?

“The side effects of chemotherapy are difficult, but AML often goes into remission with chemotherapy.”

A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient?

Transfuse leukocyte-reduced PRBCs

A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). What is the best approach for the nurse to assist the patient with this treatment decision

Inquire whether there are questions or concerns about HSCT.

Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma?

Monitor fluid intake and output.

Which nursing intervention is appropriate for a patient with non-Hodgkin’s lymphoma whose platelet count drops to 18,000/μL during chemotherapy?

Test all stools for occult blood.

A patient receiving outpatient chemotherapy for myelogenous leukemia develops an absolute neutrophil count of 850/μL. Which collaborative action should the outpatient clinic nurse anticipate?

Teach the patient to administer filgrastim (Neupogen) injections.

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider?

The patient is difficult to arouse.

The nurse is planning to administer a transfusion of packed blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

Obtain the patient’s temperature and blood pressure before the transfusion.

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

Administer PRN acetaminophen (Tylenol).

A patient in the emergency department reports back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. What should the nurse’s first action be?

Disconnect the transfusion and infuse normal saline.

Which patient should the nurse assign as the roomate for a patient who has aplastic anemia?

A patient with chronic heart failure

Which patient requires the most rapid assessment and care by the emergency department nurse?

The patient with neutropenia who has a temperature of 101.8° F.

A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets?

Platelet count is 42,000/L.

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provide

Tarry stools

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?

Notify the health care provider.

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first?

Infuse normal saline 500 mL over 30 minutes.

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/VN)?

Administering subcutaneous filgrastim (Neupogen) injection

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?

A 23-yr-old with no previous health problems who has a nontender axillary lump

After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first?

A 33-yr-old with a fever of 100.8° F (38.2° C)

Which action will the nurse include in the plan of care for a patient who has thalassemia major

Administer chelation therapy as needed.

Which information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?

Serum iron level

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?

Calf swelling and pain

Following successful treatment of Hodgkin’s lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching?

Need for follow-up appointments to screen for malignancy

A patient who has non-Hodgkin’s lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?

Lip swelling

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provide

Serum calcium level is 15 mg/dL.

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?

Schedule immunization with the pneumococcal vaccine

The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider?

History

Fatigue, which has increased over last month • Frequent constipation

Physical Assessment

Conjunctiva pale pink, moist
• Multiple bruises
• Clear lung sounds

Laboratory Results

Hct 33%
• WBC 1500/μL
• Platelets 70,000/μL

Neutropenia

When admitting an acutely confused patient with a head injury, which action should the nurse take?

Ask family members about the patient’s health history.

Which finding should the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?

Flaccidity

What should the nurse include in a focused assessment of a patient’s left posterior temporal lobe functions?

Ability to understand written and oral language

How should the nurse assess the patient’s trigeminal and facial nerve function (CNs V and VII)

Touch a cotton wisp strand to the cornea.

Which action should the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?

Withhold oral fluids and food.

An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider should the nurse question?

Prepare the patient for lumbar puncture.

A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?

Help the patient to a lateral position.

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse’s directions to move his hands and feet. What should the nurse suspect as a likely cause of these findings?

Frontal lobe damage

A patient has a tumor in the cerebellum. What goal should the nurse use to focus the plan of care?

Prevent falls.

Which problem should the nurse expect for a patient who has a positive Romberg test result?

Falls

Which test should the nurse anticipate discussing with a patient who has a possible seizure disorder?

Electroencephalography (EEG)

Which equipment should the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction?

Tuning fork

Which information about a 76-yr-old patient should the nurse identify as uncharacteristic of normal aging?

Unintended weight loss of 15 pounds

The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further teaching about neurologic assessment?

Asks the patient if the instrument feels sharp.

1Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider?

Protein of 65 mg/dL (0.65 g/L)

A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans?

The patient reports a previous allergy to shellfish.

Which of the following should the nurse consider the priority nursing assessment for a patient being admitted with a brainstem infarction?

Respiratory rate

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient should the nurse assess first?

A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram

Which assessments should the nurse make to monitor a patient’s cerebellar function? (Select all that apply.)

Observe arm swing with gait.

Perform the finger-to-nose test.

Which nursing actions should be included in the plan of care for a patient after cerebral angiography? (Select all that apply.)

Observe for bleeding at the puncture site.

Check pulse and blood pressure frequently.

Assess orientation to person, place, and time.

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation?

“The monitoring system helps show whether blood flow to the brain is adequate.”

Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mmHg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?

Decorticate posturing

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication’s effectiveness?

Intracranial pressure

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How should the nurse record the patient’s Glasgow Coma Scale score?

11.

An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient’s spouse and teenage children stay at the patient’s side and ask many questions about the treatment. What action is best for the nurse to take?

Allow the family to stay with the patient and briefly explain all procedures to them.

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

Keep the head of the bed elevated to 30 degrees.

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?

Check the drainage for glucose content.

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

Provide discharge instructions about monitoring neurologic status.

A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take?

Prepare the patient for craniotomy.

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient’s nose. Which admission order should

the nurse question?

Insert nasogastric tube to low suction.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome?

Short-term memory

When assessing a patient who has a right frontal lobe tumor, what finding should the nurse expect?

Impaired judgment

1Which statement by a patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse?

I am going to drive home and go right to bed.”

After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has weakness, impaired physical mobility, and a decreased level of consciousness. Which nursing action will be included in the plan of care?

Perform range-of-motion (ROM) exercises every 4 hours.

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?

Encourage family members to remain at the bedside.

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?

Encourage immunization for adolescents and college freshmen.

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

Staff have entered the patient’s room without a mask.

When assessing an adult who has bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention?

The patient’s blood pressure is 88/42 mm Hg.

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

Report the BP and ICP to the health care provider.

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?

Ensure that the patient’s neck is in neutral position.

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?

A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now reporting a headache. Which prescribed intervention should the nurse implement first?

Administer IV 5% hypertonic saline.

After the emergency department nurse has received a status report on the following patients with head injuries, which patient should the nurse assess first?

A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

Temperature of 101.4° F (38.6° C)

After evacuation of an epidural hematoma, a patient’s intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?

Temperature of 101.6° F

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

The staff nurse suctions the patient routinely every 2 hours.

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?

Check oxygen saturation.

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to the unlicensed assistive personnel (UAP) who regularly works in the intensive care unit?

Check capillary blood glucose level every 6 hours.

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse

Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg

The nurse is caring for a patient who has a head injury and fractured right arm. Which assessment information requires rapid action by the nurse?

The patient is more difficult to arouse.

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions?

Pale yellow urine output of 1200 mL over the past 2 hours.

While admitting a 42-yr-old patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?

The patient takes warfarin (Coumadin) daily.

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first?

Swab the nasopharyngeal mucosa for cultures

A patient with possible viral meningitis is admitted to the nursing unit after a lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question?

Restrict oral fluids to 1000 mL/day.

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?

Encourage the use of effective insect repellent during mosquito season.

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for related functional deficits?

Are you experiencing vision problems?”

During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe?

1

Which is the correct point on the accompanying figure where the nurse will assess for ecchymosis when admitting a patient with a basilar skull fracture?

D

What topic should the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, and dysarthria with no residual effects?

Oral low-dose aspirin therapy

patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin?

The patient reports that symptoms began with a severe headache.

A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect?

Difficulty comprehending instructions

During change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. What finding should the nurse anticipa

Visual deficits

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel (Plavix)?

Call the health care provider if stools are tarry.

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?

The obstructing plaque is surgically removed from inside an artery in the neck.”

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

Start a labetalol drip to keep BP less than 140/90 mm Hg.

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient?

Tissue plasminogen activator (tPa) infusion

A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate?

Ask questions that the patient can answer with “yes” or “no.”

What concern should the nurse anticipate for a patient who had a right hemisphere stroke?

Denial of deficits and impulsiveness

Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke??

Place needed objects on the patient’s left side.

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care?

Assist the patient to eat with the right hand.

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care?

Apply intermittent pneumatic compression stockings.

A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take?

Assist the patient into a chair.

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

Check the respiratory rate and effort.

Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program?

Assist the patient onto the bedside commode every 2 hours.

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, “I don’t need the aspirin today. I don’t have a fever.” Which action should the nurse take?

Explain that the aspirin is ordered to decrease stroke risk.

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the patient?

Aspirin

A patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond?

Teach the family that emotional outbursts are common after strokes.

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address?

The patient’s usual blood pressure (BP) is 170/94 mm Hg.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

The patient has atrial fibrillation and takes warfarin (Coumadin)

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first

Computed tomography (CT) scan

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient?

Risk for aspiration

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

The patient’s blood pressure (BP) is 90/50 mm Hg.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?

Administer the prescribed short-acting insulin.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first?

A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?

The patient has difficulty speaking

The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on patient information shown in the accompanying figure, which action should the nurse

Provide support to the spouse caregiver.

A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol?(SATA)

Administer oxygen to keep O2 saturation >95%.
Use National Institute of Health Stroke Scale to assess patient.

Obtain CT scan without contrast.

Infuse tissue plasminogen activator (tPA).

The nurse should determine that teaching about migraine headaches has been effective when the patient says which of the following?

I will lie down someplace dark and quiet when the headaches begin.”

Which finding should the nurse expect when assessing a patient who is experiencing a cluster headache

Unilateral ptosis

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

Time and observe and record the details of the seizure and postictal state.

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, “I cannot teach any more. It will be too upsetting if I have a seizure at work.” How should the nurse respond to specifically address the patient’s concern?

“Epilepsy usually can be well controlled with medications.”

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication

Inspect the oral mucosa.

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse should know that this history is consistent with what type of seizure?

Focal-onset

What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?

Inquire about urinary tract problems.

A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. How should the nurse respond?

Symptoms of MS are likely to improve during pregnancy.”

A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information should the nurse include in patient teaching?

How to draw up and administer injections of the medication?

Which information about a patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)?

The patient has increased serum creatinine.

Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

Teach the patient how to use the Credé method.

A patient with Parkinson’s disease has bradykinesia. Which action should the nurse include in the plan of care?

Suggest that the patient rock from side to side to initiate leg movement.

What should the nurse advise a patient with myasthenia gravis (MG) to do?

Complete physically demanding activities early in the day.

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient?

Diphenhydramine

A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which action should the nurse include in the plan of care?

Assist with active range of motion (ROM).

A 40-yr-old patient is diagnosed with early Huntington’s disease (HD). What information should the nurse provide when teaching the patient, spouse, and adult children about this disorder?

Genetic testing is an option for the children to determine their HD risk.

A 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling–type tremor. What should the nurse anticipate explaining to the patient

Antiparkinsonian drugs

A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take?

Ask the patient to keep a headache diary.

A hospitalized patient reports a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medication should the nurse administer initially?

acetaminophen (Tylenol)

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches that are present on wakening. Which action should the nurse plan to take first?

Discuss the need to stop taking the acetaminophen.

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

The patient had a recent acute myocardial infarction.

The nurse observes a patient ambulating in the hospital hall. The patient’s arms and legs suddenly jerk and the patient falls to the floor. What action should the nurse take first?

Assess the patient for a possible injury

Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?

Administer lorazepam (Ativan) 4 mg IV.

The home health registered nurse (RN) is planning care for a patient with seizure disorder related to a recent head injury. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?

Place medications in the home medication organizer

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson’s disease. Which assessment finding should indicate to the nurse that a change in the medication or dosage may be needed?

Uncontrolled head movement

Which patient problem should the nurse identify as of highest priority for a patient who has Parkinson’s disease and is unable to move the facial muscles?

Inadequate nutrition

Which assessment should the nurse identify as most important regarding a patient with myasthenia gravis?

Respiratory effort

After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient reports nausea and severe abdominal cramps. Which action should the nurse take first?

Notify the patient’s health care provider.

A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?

Start the prescribed PRN O2 at 6 L/min.

Which intervention should the nurse include in the plan of care for a patient who has primary restless legs syndrome (RLS) and is having difficulty sleeping?

Suggest that the patient exercise regularly during the day.

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

Patient has slight elevations in liver function test results.

After change-of-shift report, which patient should the nurse assess first?

Patient with myasthenia gravis who is reporting increased muscle weakness.

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient’s assigned room? (Select all that apply.)

Side rail pads

Oxygen mask

Suction tubing

A patient with Parkinson’s disease is admitted to the hospital for treatment of pneumonia. Which interventions should the nurse include in the plan of care? (Select all that apply.)

Provide an elevated toilet seat.

Cut patient’s food into small pieces.

Place an armchair at the patient’s bedside.

A patient hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia?

The patient was oriented and alert when admitted.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who is admitted for other health problems?

Remind the patient frequently about being in the hospital.

What action should the nurse incorporate when administering a mental status examination to a patient with delirium?

Choose a place without distracting stimuli.

The nurse is concerned about a postoperative patient’s risk for injury during an episode of delirium. What is the nurse’s most appropriate action?

Assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.

A patient seen in the outpatient clinic is newly diagnosed with mild cognitive impairment (MCI). Which action will the nurse include in the plan of care?

Discuss the preventive use of acetylcholinesterase medications.

The nurse is administering a mental status examination to a patient who has hypertension. The nurse suspects depression when the patient responds to the nurse’s questions with

I don’t know.”

A patient is diagnosed with moderate dementia after multiple strokes. What would the nurse expect to find during assessment of the patient?

Loss of recent and long-term memory.

Which action will help the nurse determine whether a new patient’s confusion is caused by dementia or delirium?

Use the Confusion Assessment Method tool.

A 72-yr-old patient is brought to the clinic by the patient’s spouse, who reports that the patient is unable to solve common problems around the house. To obtain information about the patient’s current mental status, which question should the nurse ask the patient?

“What did you eat for lunch

A patient is being evaluated for Alzheimer’s disease (AD). What should the nurse explain to the patient’s adult children?

A diagnosis of AD is made only after other causes of dementia are ruled out.

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia?

Having the patient’s family member administer the medication

A patient who has severe Alzheimer’s disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care?

Maintain a consistent daily routine for the patient’s care.

A patient with Alzheimer’s disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?

Place the patient in a room close to the nurses’ station.

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take?

Keep window blinds open during the day.

What should be the nurse’s initial action for a patient with moderate dementia who develops increased restlessness and agitation?

Assess for factors that might be causing discomfort.

When administering the Mini-Cog exam to a patient with possible Alzheimer’s disease, which action will the nurse take?

Ask the patient to indicate a specific time on a clock drawing.

Which hospitalized patient will the nurse assign to the room closest to the nurses’ station?

Patient with new-onset confusion, restlessness, and irritability after surgery

After change-of-shift report on the Alzheimer’s disease/dementia unit, which patient will the nurse assess first?

Patient who developed a new cough after eating breakfast.

After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimer’s disease (AD), which topic will be most important for the nurse to discuss with the patient?

Tobacco use

The spouse of a 67-yr-old male patient with early stage Alzheimer’s disease (AD) tells the nurse, “I am exhausted from worrying all the time. I don’t know what to do.” Which actions are best for the nurse to take at this time? (Select all that apply.)

Offer ideas for ways to distract or redirect the patient

Teach the spouse about adult day care as a possible respite.

Ask the spouse what she knows and has considered about dementia care options.

Which actions could the nurse delegate to a licensed practical/vocational nurse (LPN/VN) who is part of the team caring for a patient with Alzheimer’s disease? (Select all that apply.

Administer the prescribed memantine (Namenda).

Remove potential safety hazards from the patient’s environment.

What information would the nurse seek from a patient with newly diagnosed trigeminal neuralgia?

Triggers leading to facial discomfort

Which patient assessment would help the nurse identify potential complications of trigeminal neuralgia?

Inspect the oral mucosa and teeth.

What action would help the nurse evaluate outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia?

Ask the patient about social activities with family and friends.

Which action would the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia?

Assess fluid and dietary intake.

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell’s palsy. Which information should the nurse include in teaching the patient?

Call the doctor if you experience pain or develop herpes lesions near the ear.”

A patient with Bell’s palsy refuses to eat while others are present because of embarrassment about drooling. What is the nurse’s best response?

Respect the patient’s feelings and arrange for privacy at mealtimes.

To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?

Assist to plan a prescribed bowel program.

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse’s most immediate action?

The patient is continuously drooling saliva.

A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate?

Infusion of immunoglobulin

A construction worker arrives at an urgent care center with a deep puncture wound from a rusty nail. The patient reports having had a tetanus booster 6 years ago. What intervention should the nurse anticipate?

Administration of the tetanus-diphtheria (Td) booster

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which finding on the nursing assessment is congruent with neurogenic shock?

Hypotension and warm extremities

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which action should the nurse include in the plan of care?

Positioning the patient’s left leg when turning the patient

What should the nurse explain to the patient who has a T2 spinal cord transection injury?

Function of both arms should be maintained.

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?

Instruct the patient how to self-catheterize.

What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr-old patient with a C6 spinal cord injury?

Propel a manual wheelchair on a flat surface.

A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, “I want to be transferred to a hospital where the nurses know what they are doing.” Which action should the nurse appropriately take?

Ask the patient to provide input for the plan of care.

A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. What should the nurse identify as the most appropriate action at this phase of rehabilitation?

Develop a plan to increase the patient’s independence in consultation with the patient and the spouse.

A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by the health care provider should the nurse question?

Encourage oral fluids to 3 L/day.

Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Assessment of respiratory rate and effort

A patient is hospitalized with new onset of Guillain-Barré syndrome. What should the nurse recognize as the most essential assessment to complete?

Observing respiratory rate and effort

What action should the nurse identify as most important before administering botulinum antitoxin to a patient in the emergency department?

Administer an intradermal test dose.

A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. What initial intervention should the nurse perform?

Push upward on the epigastric area as the patient coughs.

A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, “I have a pounding headache and I feel sick to my stomach.” Which action should the nurse take first?

Assess the blood pressure (BP).

A patient is being evaluated for a possible spinal cord tumor. Which finding should the nurse recognize as requiring the most immediate action

The patient has new-onset weakness of both legs.

Which nursing action for a patient with Guillain-Barré syndrome should the nurse identify as appropriate to delegate to experienced unlicensed assistive personnel (UAP)?

Performing passive range of motion to extremities

Which action should the nurse take when caring for a patient who develops tetanus from injectable substance use?

Provide a quiet environment.

Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury?

Catheterize patient every 3 to 4 hours.

After change-of-shift report on the neurology unit, which patient should the nurse assess first?

Patient with botulism who is drooling and experiencing difficulty swallowing.

Which assessment finding in a patient with a spinal cord tumor requires immediate action by the nurse?

Decreased ability to move the legs

A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which information should the nurse include in an initial response?

Multiple options are available to maintain sexuality after spinal cord injury.

Which collaborative and nursing actions should the nurse include in the plan of care for a patient who experienced a T2 spinal cord transection 24 hours ago? (Select all that apply.)

Urinary catheter care

Continuous cardiac monitoring

Administration of H2 receptor blockers

Maintenance of a warm room temperature