1. The Nurse cares for the client diagnosed with a stroke resulting

Question 1. The Nurse cares for the client diagnosed with a stroke resultingin residual paralysis with spasticity. To prevent plantar flexion of the client’s feet. It is most important for the nurse to take which action?a. Reposition the client in bed every 2 hours.b. Massage the client’s feet and ankles every 4 hours.c. Instruct the client to wear high top tennis shoes at interval throughout the day.d. Position the client’s feet against a footboard during waking hours.  2. The nurse stops by the grocery store on the way home from work and sees the older person grab the chest and fall to the ground in the parking lot. The nurse rushes over and turns the person on the back. The nurse establishes that the person is unresponsive. Which action should the nurse take next?a. Ask a bystander to call 911.b. Use head-tilt, chin-lift method to open the airway.c. Palpate the carotid artery for a pulse.d. Check the client for airway obstruction.  3. The nurse in the outpatient clinic assesses the client with a medical diagnosis of acute tension-type headaches. When taking the client’s history, the nurse expects the client to report which description of the headache?a. “My headaches occur about six to eight times per week with a severe pain above my left eye that lasts about 20 minutes”b. “The headache is a sharp, excruciating pain in the left side of the face which starts after I brush my teeth and lasts for 5 minutes”c. My headache affects both sides of my head with a moderate intensity that becomes worse when I am physically active”d. “I sometimes feel the headache on one side of my head with severe intensity that is preceded by a sensation of warmth” 4. The client is admitted with a medical diagnosis of gastric adenocarcinoma. Which question or statement by the nurse indicates that the nurse understands the major predisposing factor associated with stomach cancer?a. “You stated earlier that you stopped smoking 15 years ago”b. “Have you ever been treated for H. pylori infection?c. “What kind of foods do you eat on a lactovegetarian diet?”d. “I see in your chart that your blood type is O positive”  5. The nurse supervises the graduate nurse caring for the client diagnosed with a leg ulcer secondary to venous insufficiency. The nurse should intervene if the graduate nurse is observed performing which action?a. Placing protective boots on both of the client’s legs.b. Elevating the foot of the bed above the level of the client’s heart.c. Cleaning the ulcer gently with mild soap and lukewarm water.d. Applying a heating pad over the leg dressing.   6. The nurse cares for the client diagnosed with a subdural hematoma experiencing increased intracranial pressure (ICP). To reduce the ICP, the nurse should include which intervention?a. Administer stool softeners to the client.b. Cover the client with warmed blankets.c. Turn on the radio to classical music and place it near the client’s bed.d. Offer the client sips of water every 20 minutes while awake.  7. The nurse plans discharge for the client diagnosed with dysphagia secondary to a stroke. The discharge teaching involves teaching the client’s spouse how to feed the client. Which statement by the client’s spouse indicates to the nurse that further teaching is needed?a. “I should place the food in the unaffected side of the mouth”b. “My spouse should put the head back slightly while trying to swallow”c. “I should add thickener to all liquids to make them a honey consistency”d. “My spouse should sit in a chair for all meals”  8. The nurse cares for the adult client diagnosed with pneumonia. An outcome for this client is “Client will have no signs of hypoxia and no complications related to pneumonia.” Which observation by the nurse indicates that the client outcome is met?a. The client performs ADLs without dyspnea.b. The client loses 10 pounds of body weight.c. The client’s respiratory rate is 25-30 breaths per minute.d. The client reports chest pain that is relieved by splinting the ribcage.  9. The nurse monitors the graduate nurse who is preparing to administer a Mantoux test for the client exposed to tuberculosis. The nurse determines that the graduate nurse has prepared the injection correctly if which observed?a. 0.1 mL of purified protein derivative in a tuberculin syringe with a 1/2-inch, 26-gauge needle.b. 0.1 mL of purified protein derivative in a 1-mL syringe with a 5/8-inch, 21 gauge needle.c. 0.1 mL of vitamin B6 (pyridoxine) in a tuberculin syringe with a 5/8 inch, 25 gauge needle.d. 0.5 mL of isoniazid in a tuberculin syringe with a ½ inch, 27 gauge needle. 10. The older client is diagnosed with primary open-angle glaucoma on a routine examination by the ophthalmologist. When taking the client’s history, the nurse expects the client to make which statement?a. “The pain in my eye has caused me to be sick to my stomach”b. “I can’t adjust my vision very quickly when they turn the lights out in the movie theater”c. “I am not having any trouble with my eyes”d. “My vision has been very blurry recently”  11. The nurse cares for the client diagnosed with a cervical spine injury immobilized by Crutchfield tongs. When caring for this client, which nursing intervention is most important?a. Encourage client to discuss feelings.b. Provide information about spinal cord injury.c. Inspect all skin areas at least q 2 h.d. Foster decision-making regarding care.  12. The nurse cares for the jaundiced client admitted to rule out pancreatic cancer. On admission, the nurse expects the client to report which sign or symptom?a. “I have gained about 10 pounds in 2 weeks”b. “I have severe pain in my right lower quadrant”c. “I am hungry and thirsty all the time”d. “My stools are clay-colored”  13. The client is suspected of having coronary artery disease (CAD). The client reports nausea, vomiting, “heaviness” in the chest, and diaphoresis. The nurse knows that which occurrence exacerbates this condition?a. Ingestion of antacids.b. Hypotension.c. Cigarette smoking.d. Drinking warm liquids.  14. The nurse admits the elderly client to the emergency department. A family member states that the client has had cold symptoms for several days and is taking guaifenesin cough syrup. On assessment, the nurse finds temperature 97.2F (36.2C), pulse 108 bpm, respirations 30 and shallow, BP 90/50. Diminished breath sounds over the right lower lobe, and capillary refill >5 seconds. The client is confused and lethargic. Which action should the nurse take first?a. Teach the client effective coughing techniques to remove secretions.b. Prepare the client for nebulized breathing treatment with bronchodilator. c. Ask the family member if the client received the pneumonia vaccine recently.d. Administer oxygen 2 L/min per nasal cannula through a heated, humidified system.  15. The nurse cares for the client diagnosed with a stroke and admitted 12 hours ago. The client is aphasic. The nurse enters the client’s room and witnesses a nursing student trying to communicate with the client. Which action by the student nurse requires the nurse to intervene?a. The student nurse completes sentences for the client.b. The student nurse speak to the client slowly and clearly. c. The student nurse looks directly at the client when the client tries to speak. d. The student nurse allows the client time to process the information and respond.   Health Science Science Nursing MED SURG 3215 Share QuestionEmailCopy link Comments (0)