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NUR480 Exam 3 Questions And 100% Correct Answers
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NUR480 Exam 3 Questions And 100% CorrectAnswers 2024-2025
The nurse will make sure to include what when planning for discharge planning for the
client with bacterial meningitis?
1. Keep all family and visitors from visiting your room for protective isolation.
2. Make sure you eat high protein diet with plenty of fluids
3. Take all of the antibiotics until gone.
4. Incorporate regular exercise with an active range of motion.
The client should be educated to take all antibiotics until they are gone. If antibiotics are
not completed, there is a possibility of re-infection and the infection may spread leading
to endocarditis or other infections within the body. This would be true especially if the
bacteria were from streptococci. While the client may be in isolation while in the
hospital, family may not need to quarantine the client when at home. Some family
members may get prophylactic antibiotics but these will be ordered according to the
bacterial strain and HCP recommendations. It is significant to eat a good diet, but the
most important will be taking prescribed antibiotics. Although resuming exercise is
important, it needs to be gradually increased, and the answer selection for exercise was
not as important as prescribed antibiotics.
The nurse is assessing the central stimulus function of an unconscious client who is in
the intensive care unit. The nurse should plan to institute the use of what measure to
assess the client's central response to stimuli?
1. Supraorbital ridge pressure.
2. Sternal rub.
3. Pressure on the nail bed.
4. Calling out loudly near the client's ear. - ANSWER 1. Supraorbital ridge pressure.
,Central stimulus is applied to cranial nerves not peripheral nerves. Pressure on the
orbital rim or supraorbital ridge pressure is indicated for central stimulus assessment.
The best practices do not usually indicate sternal rub. Pressure on the nail bed
represents painful stimuli testing for motor testing on peripheral nerves. Calling out
loudly is not an assessment technique for central stimulus function. Pain stimulus has
two anatomic locations centrally and peripherally. Central involves trapezious pinch or
supraorbital pressure whereas peripheral stimuli are applied to extremities. Responses
may infer damage to the brain or specific brain areas.
A client is admitted for observation after a motor vehicle accident on the way to the
client's daughter's wedding. The next morning, rather than inquiring about the wedding,
the client tells the nurse "I need to go now as the wedding is in a few minutes." The
client becomes agitated after the nurse re-orients and advises the client of the correct
date (day after the wedding). What is the nurse's next action?
1. Change the whiteboard in the client's room to reflect yesterday's date.
2. Neurological assessment, assess pupillary response
3. Valium 40 mg IV-the client is going to seize
4. Call the family to determine if the wedding can be repeated - ANSWER 2. Neurological
assessment, assess pupillary response.
The nurse should perform a neuro assessment to assess pupillary response, ask about
the presence of a headache, monitor vital signs, and notify the health care provider. The
client may be exhibiting subtle signs of increased intracranial pressure that include
restlessness, agitation, headache, and changes in pupils.
A client is taking felbamate (Felbatol) for seizures and exhibits signs of pancytopenia
based on which assessment findings? (Select all that apply)
1. Sore throat
2. Epistaxis
3. Skin rash
4. Gingival hyperplasia - ANSWER 1. Sore throat
,2. Epistaxis
Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-like
feeling and may exhibit increased bleeding with reduced platelet count (epitaxis). Rash
of the skin may not indicate pancytopenia. Gingival hyperplasia is an adverse affect of
anticonvulsants like phenytoin but is not a symptom of pancytopenia. Pancytopenia
affects red cells, white cells and platelets and represents bone marrow's response to
on-hematologic conditions such as drugs.
A client is being discharged with a new prescription of phenytoin sodium (dilantin).
Which instruction by the nurse is most important to include?
1. If stopped abruptly, status epilepticus may occur.
2. Sulfonamides such as Bactrim will decrease the levels of phenytoin in the blood.
3. Take the medication with antacids to minimize gastric upset.
4. Dilantin will not affect the effectiveness of contraceptives. - ANSWER 1. If stopped
abruptly, status epilepticus may occur.
It is necessary to teach the patient not to abruptly discontinue phenytoin sodium
(Dilantin) because this may pose a risk for return of life-threatening seizure activity.
Sulfonamides will increase phenytoin levels. The medication should not be taken with
antacids and will lower phenytoin absorption. Clients who are on contraceptive
hormone therapy may need to use alternative forms of non-hormonal contraceptives
while on phenytoin sodium (Dilantin).
The nurse is caring for an unconscious client who is receiving enteral feedings via a
nasogastric tube. Which of the following actions is the priority when managing enteral
feedings?
1. Weigh client daily at the same time.
2. Sterile water and sterile gavage system changed every 24 hours
3. Client is maintained in semi-fowlers position.
4. Warm the formula by placing in hot water 30 minutes before administration. -
, ANSWER 3. Position the client in semi-fowlers position.
It is most important to maintain semi-Fowler's position with nasogastric feedings to
prevent aspiration. Although important, daily weights are not as crucial as protection of
the airway and lungs from aspiration. Sterile water and supplies are also not necessary
since the management is with clean and not sterile procedure. The formula should be at
room temperature and must never be heated prior to administration.
The nurse will collaborate with the interdisciplinary team to plan communication
assistance for a client who has expressive aphasia. Which of the following interventions
does the interdisciplinary team decide on to assist with the client's communication?
Viagra
1. This communication is An educated staff speak slowly and in short sentences for the
client to understand.
2. All staff speak loudly for the client to hear.
3. All staff write on a clipboard for the client to read communication.
4. Make sure all staff assist client with the use of a picture board that is client-driven. -
ANS 4. Make sure all staff assist client with the use of a picture board that is
client-driven.
The expressive aphasia client may comprehend what is said or written; however, the
client may not be able to express needs verbally. A picture or communication board
helps the client because the client can point to or direct others toward objects on the
board for wants and needs. Speaking loudly or slowly is not therapeutic regarding
communication and may diminish the client's dignity. Having the staff be the only ones
writing implies one-way communication that is staff-driven and not client-need driven.
The focus is client-centered care and the client should be encouraged to express needs
and wants through therapeutic means.
The nurse is caring for a client with increased intracranial pressure. Which respiratory
pattern changes will signal increased intracranial pressure?
1. Rapid, shallow respirations.
2. Nasal flaring.
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