MED SURG P1-P2 THIRD YR LAST YEAR PART 1.

A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? * 1/1 Prepare to administer recombinant tissue p ...

A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? * 1/1 Prepare to administer recombinant tissue plasminogen activator (rt-PA). Discuss the precipitating factors that caused the symptoms. Schedule for A STAT computer tomography (CT) scan of the head. Notify the speech pathologist for an emergency consult. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective? * 1/1 A. There is no skin breakdown. B. Her appetite improves. C. She loses more than 10 lbs. D. Stools are less fatty and decreased in frequency. During preoperative teaching for a female client who will undergo subtotal thyroidectomy, the nurse should include which statement? * 1/1 A. “The head of your bed must remainflat for 24 hours after surgery.” B. “You should avoid deep breathing andcoughing after surgery.” C. “You won’t be able to swallowfor thefirst day or two.” D. “You must avoid hyperextending your neck after surgery.” A nurse in the emergencydepartment is observing a4-year-old child for signs of increased intracranial pressureafter a fall froma bicycle, resulting in head trauma. Whichof the following signs or symptoms would be cause forconcern? * 1/1 Bulging anterior fontanel. Repeated vomiting. Signs of sleepiness at 10 PM. Inability to read short words froma distance of 18 inches. For a diabetic male client witha foot ulcer, the physicianorders bed rest, a wet-to-drydressing change every shift, andblood glucose monitoring beforemeals and bedtime. Why arewet-to-dry dressings usedforthis client? * 1/1 They contain exudate and provide a moist wound environment. They protect the wound frommechanical trauma and promote healing. They debride the wound and promote healing by secondary intention. They prevent the entrance of microorganisms and minimize wound discomfort. A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years? * 1/1 Electrolyte imbalance Head trauma Epilepsy Congenital defect A 38 year old woman returns from a subtotal thryroidectomy for the treatment of hyperthyroidism. Upon assessment, the immediate priority that the nurse would include is: * 1/1 Assess for pain Assess for neurological status Assess fluid volume status Assess for respiratory distress Nurse Ruth is assessing a clientafter a thyroidectomy. The assessment reveals muscle twitching and tingling, alongwith numbness in the fingers, toes, and mouth area. The nurse should suspect whichcomplication? * 1/1 A. Tetany B. Hemorrhage C. Thyroid storm D. Laryngeal nerve damage A female client admittedtoanacute care facility after acaraccident develops signs andsymptoms of increasedintracranial pressure (ICP). Theclient is intubated andplacedon mechanical ventilationtohelp reduce ICP. To prevent afurther rise in ICP causedbysuctioning, the nurse anticipatesadministering which drugendotracheally before suctioning? * 1/1 Phenytoin (Dilantin) Mannitol (Osmitrol) Lidocaine (Xylocaine) Furosemide (Lasix) A neurological consult has been ordered for a pediatric client with suspected petit mal seizures. The client with petit mal seizures can be expected to have: * 0/1 Short, abrupt muscle contraction Quick, bilateral severe jerking movements Abrupt loss of muscle tone A brief lapse in consciousness Correct answer A brief lapse in consciousness A female adult client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which “related-to” phrase should the nurse add? * 1/1 A. Related to bone demineralization resulting in pathologic fractures B. Related to exhaustion secondary to an accelerated metabolic rate C. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces D. Related to tetany secondary to a decreased serum calcium level Dr. Rodriguez prescribes glipizide (Glucotrol), anoral antidiabetic agent, for a maleclient with type 2 diabetes mellitus who has been havingtrouble controlling the bloodglucose level through diet andexercise. Which medicationinstruction should the nurseprovide? * 1/1 “Be sure to take glipizide 30 minutes before meals.” “Glipizide may cause a low serumsodiumlevel, so make sure you have your sodiumlevel checked monthly.” “You won’t need to check your blood glucose level after you start taking glipizide.” “Take glipizide after a meal to prevent heartburn.” The nurse is formulating ateaching plan for a client whohas just experienced a transientischemic attack (TIA). Whichfact should the nurse includeinthe teaching plan? * 1/1 TIA symptoms may last 24 to 48 hours. Most clients have residual effects after having a TIA. TIA may be a warning that the client mayhave cerebrovascular accident (CVA) The most common symptomof TIAis theinability to speak. Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse 96, respirations 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube. Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation? * 1/1 A. “It empties the stomach of fluids and gas.” B. “It prevents spasms at the sphincter of Oddi.” C. “It prevents air from forming in the small intestine and large intestine.” D. “It removes bile from the gallbladder.” After undergoing a subtotal thyroidectomy, a female client develops hypothyroidism. Dr. Smith prescribes levothyroxine (Levothroid), 25 mcg P.O. daily. For which condition is levothyroxine the preferred agent? * 1/1 A. Primary hypothyroidism B. Graves’ disease C. Thyrotoxicosis D. Euthyroidism A client with type 1DMcalls the nurse to report recurrentepisodes of hypoglycemia withexercise. Which statement bythe client indicated aninadequate understandingof the peak action of NPHinsulinand exercise? * 1/1 A. “The best time for me to exercise is every afternoon.” B. “The best time for me to exercise is right after I eat.” C. “The best time for me to exercise is after breakfast.” D. “The best time for me to exercise is after my morning snack.” The physician orders laboratorytests to confirmhyperthyroidismin a femaleclient with classic signs andsymptoms of this disorder. Which test result wouldconfirmthe diagnosis? * 1/1 No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test A decreased TSH level An increase in the TSH level after 30 minutes during the TSH stimulation test Below-normal levels of serumtriiodothyronine (T3) and serumthyroxine(T4) as detected by radioimmunoassay