NUR480 Exam 3 Questions With Correct
Answers
In planning for discharge planning for a client with bacterial meningitis, the nurse will be sure to
include which instruction?
1. Keep all family and visitors from visiting your room for protective isolation.
2. Make sure you eat high protein diet ...
In planning for discharge planning for a client with bacterial meningitis, the nurse will be sure to
include which instruction?
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. - answer✔3. Take all of the
antibiotics until gone.
The client should be instructed to complete all antibiotics until they are completely gone. Failure
to complete antibiotics may lead to re-infection and may spread causing endocarditis and other
infections in the body, 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 receive prophylactic antibiotics, but will be ordered according to the
bacterial strain and health care provider (HCP) recommendations. It is important to eat a good
diet, but the most important will be taking prescribed antibiotics. While returning to exercise is
important, gradual increase should be performed, 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 in the intensive care
unit. The nurse should plan to use which technique to test the client's central response to stimuli?
1. Supraorbital ridge pressure.
2. Sternal rub.
3. Pressure on the nail bed.
4. Calling out loudly close to the client's ear. - answer✔1. Supraorbital ridge pressure.
Central stimulus is applied to cranial nerves not peripheral nerves. Supraorbital ridge pressure by
applying pressure on the orbital rim is indicated for central stimulus assessment. Sternal rub is
usually not indicated via best practices. Pressure on the nail bed represents testing painful stimuli
for motor testing on peripheral nerves. Calling out loudly is not an assessment technique for
central stimulus function. There are two anatomic locations for pain stimulus: 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 following a motor vehicle accident that occurred on the way
to the client's daughter's wedding. The next morning, instead of asking about the wedding, the
client tells the nurse "I have to leave now since the wedding is in a few minutes." The client then
becomes agitated when the nurse re-orients and states the actual date (which is the day following
the wedding). What should the nurse do next?
1. Change the date on the hospital room whiteboard to yesterday's date.
2. Perform neurological assessment and assess pupillary response.
3. Administer Valium 40 mg IV since the client is about to have a seizure.
4. Call the family to see if the wedding can be repeated - answer✔2. Perform neurological
assessment and assess pupillary response.
The nurse needs to perform a neuro assessment to determine pupillary response, ask if a
headache is present, take vital signs, and contact the health care provider. The client may be
exhibiting subtle signs of increased intracranial pressure which includes restlessness, agitation,
headache, and pupil changes.
A client is taking felbamate (Felbatol) for seizures and displays symptoms of pancytopenia based
on which assessment findings? (Select all that apply)
Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-like feeling, and
may exhibit increased bleeding with reduced platelet count (epitaxis). Skin rash 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 like Bactrim will decrease phenytoin levels in the blood.
3. Take the medication with antacids to reduce gastric upset.
4. Dilantin will not affect contraceptive effectiveness. - answer✔1. If stopped abruptly, status
epilepticus may occur.
It is important to instruct not to suddenly stop taking phenytoin sodium (Dilantin) as doing so
may present a risk for return of life-threatening seizure activity. Sulfonamides will increase
phenytoin levels. The drug should not be taken with antacids and will lower phenytoin
absorption. Clients on contraceptive hormone therapy may need to use alternative forms of non-
hormonal contraceptives while on phenytoin sodium (Dilantin).
The nurse is caring for a client who is unconscious who requires enteral feedings through a
nasogastric tube. Which action takes priority when managing enteral feedings?
1. Weigh the client daily at the same time.
2. Make sure sterile water and sterile gavage system is changed every 24 hours.
3. Keep the client in semi-fowlers position.
4. Keep the formula warm by setting in hot water 30 minutes prior to administration. -
answer✔3. Keep the client in semi-fowlers position.
It is most important to maintain a semi-flowlers position with nasogastric feedings to prevent
aspiration. While daily weights may be important, protecting the airway and lungs from
aspiration is more important. Having sterile water and supplies are not necessary since the
management is with clean not sterile procedure. The formula should be room temperature and
should never be heated prior to administration.
The nurse will collaborate with the interdisciplinary team on communication assist with a client
with expressive aphasia. The team decided on which intervention to help with communication?
1. Make sure all staff know to speak slowly and in short sentences.
2. Make sure all staff speak loudly for the client to hear.
3. Make sure all staff write on a clipboard for the client to read communication.
4. Make sure all staff assist the client with use of a picture board which is client driven. -
answer✔4. Make sure all staff assist the client with use of a picture board which is client driven.
Expressive aphasia clients may understand what is heard or written, but they may not be able to
verbally communicate their needs. A picture or communication board helps the client as the
client can point to or direct others towards objects on the board for wants and needs. Speaking
loudly or slowly is not therapeutic for communication and may diminish the client's dignity.
Having staff to be the only ones to write 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?
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