A. Test the drainage for glucose A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? a. Test the drainage for glucose b. Suction the nostril c...
Nur 336 Practice Questions and
Complete Solutions
A. Test the drainage for glucose ✅A nurse is assessing a client who sustained a basal
skull fracture and notes a thin stream of clear drainage coming from the client's right
nostril. Which of the following actions should the nurse take first?
a. Test the drainage for glucose
b. Suction the nostril
c. Notify the physician
D. Ask the client to blow his nose
Inability to recognize his family members ✅A nurse is caring for a client who has had a
stroke involving the right hemisphere. Which of the following alterations in function
should the nurse expect?
a. Difficulty reading
b. Inability to recognize his family members
c. Right hemiparesis
d. Aphasia
Race ✅A nurse is teaching about risk factors for developing a stroke with a group of
older adult clients. Which of the following nonmodifiable risk factors should the nurse
include in teaching?
a. History of smoking
b. Obesity
c. History of hypertension
d. Race
Cheyne-Stokes respirations ✅A nurse is caring for a client who is unconscious and
has a breathing pattern characterized by alternating periods of hyperventilation and
apnea. The nurse should document that the client has the following respiratory
alterations?
a. Kussmaul respirations
b. Apneustic respirations
c. Cheyne-Stokes respirations
d. Stridor
Hemorrhagic stroke ✅A nurse in an emergency department is caring for a client who
had a seizure and became unresponsive after stating she had a sudden, severe
headache and vomiting. The client's vital signs are as follows: blood pressure 198/110,
pulse 82 bpm, respirations 24/min, and a temperature of 38.2C (100.8F). Which of the
following neurologic disorders should the nurse suspect?
a. Transient ischemic attack (TIA)
b. Hemorrhagic stroke
c. Thrombotic stroke
,d. Embolic stroke
"What do you think your spouse would have wanted?" ✅A nurse is caring for a client
who has severe head injuries and is declared brain dead. The transplant coordinator
has spoken with the client's family about organ donation. The client's spouse states that
she is confused and does not know what she should do. Which of the following
responses by the nurse is appropriate?
a. "There is such a shortage of organs in this country, so I think you should go ahead
and consent to donate your spouse's organs."
b. "What do you think your spouse would have wanted?"
c. "Most religions support organ donation, so don't let that stand in your way."
d. "Don't you think you will feel a little better about the situation if you donate your
spouse's organs?"
Establish the ability to communicate effectively ✅A nurse at a rehabilitation center is
planning care for a client who had a left hemispheric stroke 3 weeks ago. Which of the
following goals should the nurse include int he client's rehab program?
a. Establish the ability to communicate effectively
b. Compensate for loss of depth perception
c. Learn to control impulsive behavior
d. Improve left-side motor function
"You are feeling drawn in two separate directions." ✅A nurse is caring for a client who
was admitted to the facility in critical condition following a stroke. The client's son says
to the nurse, "I wish I could stay, but I need to go home to see how my children are
doing. I really hate to leave." Which of the following responses should the nurse make?
a. "Perhaps you could call your children to see how they are doing."
b. "Don't worry. We'll take good care of your parent while you are gone."
c. "You are feeling drawn in two separate directions."
d. "There is nothing you can do here. You should go home to your children."
Restlessness ✅A nurse is caring for a client who has a traumatic brain injury (TBI).
Which of the following findings should the nurse identify as an indication of increased
intracranial pressure (ICP)?
a. Tachycardia
b. Amnesia
c. Hypotension
d. Restlessness
Perform neurovascular checks of the extremity ✅A nurse is caring for a client who is
postoperative following an open reduction and internal fixation of a fracture femur.
Which of the following actions is the most important for the nurse to complete in the
postoperative period?
a. Medicate the client for pain
b. Instruct the client on use of crutches
c. Perform neurovascular checks of the extremity
, d. Direct the client to perform exercises of the ankles and toes
Decreased LOC ✅A nurse is caring for a client who has sustained a traumatic brain
injury (TBI). The nurse should monitor the client for which of the following
manifestations of increased intracranial pressure?
a. Decreased level of consciousness
b. Tachypnea
c. Bilateral weakness of the extremities
d. Hypotension
"Respite care allows the primary caregiver time away from day-to-day care
responsibilities." ✅A nurse is planning to discharge a client who has quadriplegia to his
home. The nurse suggests that the family might need respite care services. When a
family member asks how respite care can help, which of the following responses should
the nurse provide?
a. Respite care allows the primary caregiver time away from day-to-day care
responsibilities."
b. "Respite care provides holistic support and care for a client who is terminally ill."
c. "Respite care helps relieve pain and promote comfort."
d. "Respite care is a continuation of psychological support after a family member dies."
Instruct the client to wiggle his toes ✅A nurse is caring for a client who has an
unrepaired femur fracture of the midshaft. Which of the following techniques should the
nurse use when performing an assessment of the client's neurovascular status?
a. Measure the circumference of the thigh
b. Palpate the femoral pulse
c. Monitor the client's calf for edema
d. Instruct the client to wiggle his toes
"So it seems that you feel responsible for what happened to your mother." ✅A nurse is
caring for an older adult client who had a stroke and has right-sided paralysis and
aphasia. The client's son tells the nurse it is his fault because he did not insist that his
mother live with him. Which of the following responses should the nurse make?
a. "So it seems that you feel responsible for what happened to your mother."
b."Your mother will be fine. You shouldn't worry so much."
c. "Why do you blame yourself? You could not have prevented the stroke."
d. "You are not responsible for your mother's stroke, but many people in your situation
feel this way."
"We have begun plans to send your partner to a rehabilitation facility as soon as he is
stable." ✅A nurse is caring for an older adult client who had stroke and has left-sided
weakness. The client's partner tells the nurse she is worried about the next steps of
treatment for her partner. Which of the following responses should the nurse make?
a. "We have begun plans to send your partner to a rehabilitation facility as soon as he is
stable."
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