After a 25 year old patient has returned home following rehabilitation for spinal cord injury the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation the most appropriate action by the nurse at this time is to

Develop a plan to increase the patients independence in consultation with the patient and the spouse

A nursing student asks the nurse to differentiate the pathology of alzheimer's disease from that of parkinson's disease which description is correct

Parkinson's disease is characterized by an imbalance of dopamine and acetylcholine

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 8.6g/dL(86g/L)

The nurse is preparing to administer benztropine (Cogentin) to a patient who has parkinson disease when performing an assessment which aspect of the patient's history would cause the nurse to hold the medication and notify the provider

Glaucoma

The nurse is teaching a patient with iron- deficiency anemia about foods to increase iron intake which food may enhance the absorption of oral iron forms

Orange Juice

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient which parameter should the nurse monitor to determine the medications effectiveness

Intracranial pressure

A nurse is caring for a client with a spinal cord injury with which interprofessional health team member would the nurse collaborate to assist the client with activities of daily living

Occupational therapist

The nurse is caring for a patient who has a seizure disorder the nurse knows that the patient has reddened gums that bleed when oral care is given the nurse recognizes this finding as

An adverse effect on the phenytoin

A nurse is teaching a family member about an elderly patients new prescription for tacrine (Cognex) to treat alzheimer's disease the family member asks what to expect from this drug the nurse will respond that the patient will

Have decreased deterioration of cognition

After teaching a client with a high thoracic spinal cord injury the nurse assesses the client's understanding which statement by the client indicates a correct understanding all how to prevent respiratory problems at home

I'll use my incentive spirometer every 2 hours while i'm awake

While administering a mental status examination to a patient with delirium the nurse should

Choose a place without distracting environmental stimuli

A prescriber writes this order “ Give amantadine (Symmetrel) 100 mg per PEG tube twice a day” the medication is available in a liquid form with a concentration of 50mg/5mL identify how many mL will the nurse give with each dose

10ml

Which nursing actions should be included in the plan of care for a patient after cerebral angiography (SATA)

Check pulse and blood pressure frequently

Assess orientation to person place and time

Observe for bleeding at the puncture site

The spouse of a male patient with early stage alzheimer's disease tells the nurse “I am just exhausted from the constant worry I don't know what to do which action is best for the nurse to rake next (SATA)

Educate the spouse about the availability of adult daycare as he respites

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

Offer ideas for ways to distract or redirect the patient

A patient with a neck fracture at the C5 level is admitted to the intensive care unit during initial assessment of the patient the nurse recognizes the presence of neurogenic shock on finding

Lack of movement or sensation below the level of injury

A client continues to have persistent low back pain even after using a number of nonpharmacologic pain management strategies which prescribed drug would the nurse anticipate that the client might need to manage the pain

Gabapentin

A patient who has epilepsy will begin anticonvulsant medication the patient asks a nurse how long the medication will be necessary how long will the nurse respond

The medication is usually taken for a lifetime

The nurse is providing teaching to a parents of a 5 year old child who will begin taking phenytoin(Dilantin) what information will the nurse include when teaching these parents about their child's medication

Your child may need a higher dose than expected

The nurse assesses a client who is recovering from an open traditional lumbar laminectomy with fusion which complications would the nurse report to the primary health care provider (SATA)

Sudden and severe headache

Incisional bulging

Redness and itching at the incision site

Which statement by a patient with sickle cell anemia indicates good understanding of the nurses teaching about prevention of sickle cell crisis

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

With a head injury simulation purchase 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 patients Glasgow coma scale score

11

The spouse of a patient newly diagnosed with moderate dementia as a result of multiple strokes during assessment of the patient the nurse would expect to find

Recommend exercise nutritional counseling and group support to help manage the disease

A 72 year old patient is diagnosed with moderate dementia as a result of multiple strokes during assessment of the patient the nurse would expect to find

Loss of both recent and long term memory

During the morning change of shift report at a long term care facility the nurse claims that the patient with dementia has had sundowning which nursing action put the nurse take while caring for the patien

Keep your blinds open during the daytime hours

A 52 year old patient has a new diagnosis of pernicious anemia after teaching the patient about pernicious anemia the nurse determines that the patient understands the disorder when the patient states

I would rather use the nasal spray than have to get injections of vitamin B12

A patient with end stage renal failure has been admitted to the hospital for severe anemia she is refusing blood transfusions the nurse anticipates drug therapy with which drug to stimulate the production of red blood cells

Epoetin alfa(epogen)

A woman who is planning to become pregnant should ensure that she receives adequate levels of which supplement to reduce the risk of fetal neural tube defects

Folic acid

When a patient is experiencing a cluster headache the nurse will plan to assess for

Unilateral eyelid swelling

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 confused patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests the nurse should contact the patient's family member define a consent form before the

Bone marrow Biopsy

The nurse will teach a patient who is receiving oral iron supplements so watch for which expected adverse effects

Black tarry stools

A patient will be receiving monthly injections of cyanocobalamin(Nascobal) the dose is 100mcg/month IM the medication is available in a strength of 1000mcg/ml identify how many mL will the nurse draw up to the syringe

0.1mL

The nurse assess clients at a community center which client is at the greatest risk for low back pain

A 65 year old female with osteoarthritis

A patient with parkinson's disease as admitted to the hospital for treatment of an acute infection which nursing interventions will be included in the plan of care (SATA)

Use an elevated toilet seat

Place an armchair at the patient's bedside

Cut patients food into small pieces

When a brain injury patient responds to nail bed pressures with internal rotation adduction and flexion of the arms how should the nurse report the response

Decorticate posturing

Calculate the following dosage using the dimension analysis method round mL answers to the nearest tenth unless otherwise indicated Order: thorazine 25 mg po t.i.d 12.5 mL Available: thorazine syrup labeled 10mg per 5 mL

12.5mL

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

Ask family members about the patients health history

Unearth caring for a client with paraplegia who is scheduled to participate in a rehabilitation program the client states I don't understand the need for rehabilitation the paralysis will not go away and it will not get better how would the nurse respond

Rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability

A patient has been taking iron supplements for anemia for two months during a follow up assessment the nurse will observe for which therapeutic response

Increase activity tolerance

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

Schedule immunization with the pneumococcal vaccine

A patient has a tonic clonic seizure while the nurse is in the patient's room what action will the nurse take

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

After receiving change your shift report for the following patients with neutropenia which patient would the nurse assess first

A 35 year old patient who has a fever of 100.8F (38.2C)

A nurse is caring for an older adult who receiving multiple packed red blood cells transfusions which assessment finding indicates possible infusion circulatory overload

Hypertension

A client is scheduled for a percutaneous endoscopic lumbar discectomy which statement by the client indicates a need for further teaching

I'll be in the hospital for two to three days

A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled 1 mL equals 10 drops how many drops per min will the nurse infuse

21 gtt/min

The nurse assesses a patient with pernicious anemia which finding would the nurse expect

Tender bleeding gums

The nurse initiates care for a client with a cervical spine cord injury who arrives via emergency medical services which action would the nurse take first

Evaluate respiratory status

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

Unintended weight loss of 15 pounds

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

A client hospitalized with sickle cell disease crisis frequently asks for opioid pain medications,often shortly after receiving a dose. The nurses on the unit believe that the client is drug seeking. When the client requests pain medication, What action by the nurse is best?

Give the client pain medication if it is time for another dose

The nurse is caring for a client experiencing sickle cell disease crisis. Which priority action would help prevent infection

Performing frequent handwashing

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

Folic acid

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

After teaching a patient who is scheduled for magnetic resonance imaging (MRI) the nurse assesses the client's understanding which statement indicates client understanding of the teaching

I can return to my usual activities immediately after the MRI

The nurse is assessing a client experiencing anemia which laboratory findings will the nurse expect for this client(SATA)

Decreased red blood cell count

Decreased serum iron

Decreased hemoglobin

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

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

A patient with pancytopenia will have a bone marrow aspiration from the left posterior iliac crest which action would be important for the nurse to take after the procedure

Have the patient lie on the left side for 1 hour

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

Tuning fork

The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V what assessment findings will the nurse expect for this client

Severe facial pain

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 healthcare provider should the nurse question

Prepare the patient for lumbar puncture

A client is having a radioisotopic imaging scan what action by the nurse is most important

Teach the client about the procedure

After teaching the wife of a client who has parkinson disease the nurse assesses the wifes understanding which statement by clients wife indicates that she is correctly understands changes associated with this disease

He may have trouble chewing so i will offer bite sized portions

An assistive personnel is caring for a client with leukemia and asks why the client is still at risk for infection when the white blood cell (WBC) is high what response by the nurse is correct

Those WBCs are abnormal and don't provide protection

The nurse prepares to discharge a client with early to moderate alzheimer disease which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver

Install safety locks on all outside doors

A client in sickle cell crisis is dehydrated and in the emergency department the nurse plans to start an IV which fluid is best

0.45% normal saline

The nurse is performing an assessment of cranial nerve III which testing is appropriate

Pupil constriction

The nurse assesses a patient who has numerous petechiae on both arms which question should the nurse ask the patient

Do you take medication containing salicylates

A patient is being evaluated for alzheimer's disease what should the nurse explain to the patients adult children

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

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client hips and sacrum what actions would the nurse take(SATA)

Reposition the client off the reddened areas

Apply a pressure reducing mattress

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 foods

A nurse is caring for four clients after reviewing todays laboratory results which client would the nurse assess first

Client with a prothrombin time (PT) of 28 seconds

A nurse assesses a client with a spinal cord injury at level T5 the client's blood pressure is 184/95 mmHg and the client presents with a flushed face and blurred vision after raising the head of the bed what action would the nurse take next

Palpate the bladder for distension

the nurse is reviewing laboratory results and notes a patients activated partial thromboplastin time (aPTT) level is 28 seconds the nurse should notify the healthcare provider in anticipation of adjusting which medication

Heparin

A nurse assesses cerebrospinal fluid leaking into a client's surgical dressing what actions would the nurse take (SATA)

Place the client in a flat position

Report the leak to the surgeon

A client is having a bone marrow aspiration and biopsy and is extremely anxious what action by the nurse is the most appropriate

Assess the clients fears and coping mechanisms

A patient in the emergency department reports back pain and difficulty breathing 15 mins after a transfusion of packed red blood cells is started what should the nurses first action be

Disconnect the transfusion and infuse normal saline

A client presents to the emergency department in sickle cell disease crisis what intervention by the nurse takes priority

Administer oxygen

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

Evaluating the effectiveness of opioid analgesics

What is the nurse's priority when caring for a client who just completed a bone marrow aspiration and biopsy

Check the pressure dressing frequently for signs of excessive or active bleeding

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

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

A nurse assesses a client recovering from a cerebral angiography via the right femoral artery which assessment would the nurse complete

Palpate bilateral lower extremity pulses

How should the nurse assess the patients trigeminal and facial nerve function (CNs V and VII)

Touch a cotton wisp strand to the cornea

The nurse teaches assistive personnel (AP) about how to care for a client with early stage alzheimer disease which statement would the nurse include

Reorient the client to the day time and environment with each contact

Which statement would the nurse include when teaching the assistive personnel (AP) how to care for a client with cranial nerve II impairment

Tell the client where food items are on the breakfast tray

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

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

Which assessments should the nurse make to monitor a patients cerebellar function(SATA)

Observe arm swing with gait

Perform finger to nose test