What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram Correct Answer: B. Pupil size and pupillary response It is crucial to monitor… Read More »
Emergency medical technicians transport a 27-year-old ironworker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s… Read More »
A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? A. Bloody drainage from the ears B. Frequent swallowing C. Guaiac-positive stools D. Hematuria Correct Answer: B. Frequent swallowing Frequent swallowing after brain surgery… Read More »
Which of the following symptoms would you expect to a client with a phenytoin level of 35 mg/dL? A. Ataxia B. Potassium deficit C. Neglect syndrome D. Tetraplegia Correct Answer: A. Ataxia A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 35 mg/dl signifies… Read More »
A male client with Bell’s Palsy asks the nurse what has caused this problem. The nurse’s response is based on an understanding that the cause is: A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem. B. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia. C. Primary genetic… Read More »
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? A. Document the onset time, nature of seizure activity, and postictal behaviors for… Read More »
What is the expected outcome of thrombolytic drug therapy? A. Increased vascular permeability B. Vasoconstriction C. Dissolved emboli D. Prevention of hemorrhage Correct Answer: C. Dissolved emboli. Thrombolytic therapy is used to dissolve emboli and reestablish cerebral perfusion. Thrombolytic treatment is also known as fibrinolytic or thrombolysis,… Read More »
An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to… Read More »
After a hypophysectomy, vasopressin is given IM for which of the following reasons? A. To treat growth failure. B. To prevent syndrome of inappropriate antidiuretic hormone (SIADH). C. To reduce cerebral edema and lower intracranial pressure. D. To replace antidiuretic hormone (ADH) normally secreted by the pituitary. … Read More »
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. A thrombolytic medication B. A beta-blocker medication C. An anti-hyperuricemic medication D. An oral anticoagulant medication Correct Answer: D. An… Read More »