Nur 242 exam 4 Medical-Surgical Nursing Exam | Questions and Verified Answers| 100% Correct| Grade A- Galen
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Nur 242 exam 4 Medical-Surgical Nursing Exam |
Questions and Verified Answers| 100% Correct| Grade A-
Galen
The registered nurse (RN) is caring for a client who is currently hospitalized for a
stroke. Which professional management strategy will be most effective for the RN to
...
Nur 242 exam 4 Medical-Surgical Nursing Exam |
Questions and Verified Answers| 100% Correct| Grade A-
Galen
The registered nurse (RN) is caring for a client who is currently hospitalized for a
stroke. Which professional management strategy will be most effective for the RN to
improve the safety and quality of client care? - ANSWER Delegation
The client taking intravenous coagulant medications for a bleeding disorder suddenly
develops an embolic stroke as a result of medication overdose. Which actions by the
hospital management does the Leapfrog Group suggest? Select all that apply. One,
some, or all responses may be correct. - ANSWER Apologize to the client and family.
Waive all costs directly related to the adverse effect.
Report the adverse event to The Joint Commission.
some, or all responses may be correct. - ANSWER Slow performance and caution
Impaired speech/language aphasias
Awareness of deficits with depression and anxiety
When a client has difficulty swallowing after a stroke, which action by the nurse would
be most important in preventing pneumonia? - ANSWER Having suction available
during meals
A client has had a recent brain attack (cerebrovascular accident/stroke). Which
preventative would the nurse anticipate will be prescribed daily to avoid straining due to
constipation? - ANSWER Stool softener
Which intervention would the disaster management team nurse perform for the
survivors of an explosion who developed heat stroke? - ANSWER Apply ice packs on
the client's scalp
Which level of care is the nurse providing when preparing to discharge a client who is
learning to walk again after a stroke to a rehabilitation center? - ANSWER tertiary care
Which action by the emergency department nurse is the priority for a client with heat
stroke? - ANSWER Assess the airway and breathing
A client who sustains a stroke has a loss of proprioception and fine touch. Which artery
would the nurse suspect is damaged? - ANSWER Anterior cerebral
, A client has a brain attack (stroke) that involves the right cerebral cortex and cranial
nerves. Which areas of paralysis would the nurse expect to find upon assessment?
Select all that apply. One, some, or all responses may be correct. - ANSWER Left leg
Left arm
Left side of face
Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later,
the nurse identifies that one pupil reacts more slowly than the other and the client's
systolic blood pressure is increasing. For which condition would the nurse prepare to
intervene? - ANSWER Increased intracranial pressure
The nurse observes dorsiflexion of the big toe and fanning of other toes when the
lateral side of a client's foot is stroked. Which finding would the nurse document? -
ANSWER Exhibits a positive Babinski sign
The nurse is caring for a client who had a stroke and who has varying moods ranging
from anger to depression to concern about the aphasia, hemiparesis, and the gavage
feedings. Which behavior indicates the client's acceptance of physical limitations? -
ANSWER Performs tube feedings without assistance
A client has dysarthria after a stroke. Which goal would the nurse include in the plan of
care to address this problem? - ANSWER Effective communication
Which reflex is the nurse testing when using a dull object to stroke from the lateral sole
of a client's foot upward to the great toe? - ANSWER Babinski
A client admitted to the hospital with the diagnosis of a right-sided "brain attack"
(stroke) is right-handed. Which task will be most difficult for this client? - ANSWER
Dressing every morning
The nurse assessed a client who experienced a recent brain attack (stroke) and has a
residual right-sided hemiplegia. Which rationale explains the importance of the nurse
identifying mobility restrictions or neuromuscular abnormalities when assessing this
client? - ANSWER Shortening and eventual atrophy of the affected muscles will occur
Which condition of a client with hemorrhagic stroke resulting from a motor bike accident
requires immediate attention? - ANSWER Body temperature of 81.2°F
In which order would the nurse caring for a client suffering from heatstroke provide
emergency interventions? - ANSWER Ensure a patent airway.
Remove the client from the hot environment.
Remove the client's clothing
Pour or spray cold water on the client's body and scalp.
Fan the client with newspapers or whatever is available.
Place ice in cloth or bags and position the packs on the client's scalp
, Emergency care should be provided to the client with heatstroke to restore
thermoregulation. First the nurse would ensure a patent airway. Then the nurse would
remove the client from the hot environment into air conditioning or shade and remove
his or her clothing. Then the nurse would pour or spray cold water on the client's body
and scalp. The client should be fanned with newspapers or whatever is available. This
should be followed by placing ice in cloth or bags and positioning the packs on the
client's scalp.
Which priority interventions would the nurse provide to the client hospitalized with
heatstroke, a body temperature of 106°F, and skin that is hot and dry? Select all that
apply. One, some, or all responses may be correct - ANSWER Remove the client's
clothing.
Immerse the client in cold water
Which nursing intervention is the priority for a client with stroke who is transitioned from
the emergency department (ED) to other settings? - ANSWER Assessing the level of
consciousnes
Which client condition requires a medium priority of care according to the National
Institutes of Health Stroke Scale (NIHSS) score? - ANSWER Facial palsy score of 1
The nurse is about to perform a wound irrigation on a client who had a left hemispheric
stroke 1 year ago. Which assessment is most important for the nurse to perform before
beginning the irrigation? - ANSWER pain
The body temperature of a client with heatstroke is above 104°F (40°C). Which is the
priority order the nurse would use for cooling the client so that breathing and circulation
are not impaired? - ANSWER The nurse will take off the client's clothing.
The nurse would place ice packs on the neck, axillae, chest, and groin.
The nurse would immerse the victim in cold water.
The nurse would fan the client rapidly to aid in cooling by evaporation.
Which prehospital care intervention is the priority for the client with heatstroke? -
ANSWER Withholding food or liquid to the victim
The client with which National Institutes of Health Stroke Scale (NIHSS) score would be
treated first? - ANSWER 3 for facial palsy
109 F - ANSWER 42.8 C (109-32):5/9
The nurse is planning care for an immobilized client who had a stroke with right-sided
hemiparesis. Which activity would the nurse include in the plan of care? - ANSWER
Assist the client to perform range-of-motion (ROM) exercises every 1 to 2 hours
Which is the priority nursing action for a client admitted to the hospital in a coma after
having a stroke? - ANSWER Maintain an open airway.
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