The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone
(SIADH). This condition is most often related to which predisposing condition? A)
Small cell lung cancer. B) Active tuberculosis infection. C) Hodgkin's lymphoma. D)
Tricyclic antidepressant therapy. - with c...
AND ANSWERS An ER nurse is completing an assessment on
a patient that is alert but struggles to
answer questions. When she attempts to talk, she slurs her speech and appears very
frightened. What additional clinical manifestation does the nurse expect to find if
nacy's sysmptoms have been caused by a brain attack (stroke)? A. A carotid bruit B.
A hypotensive blood pressure C. hyperreflexic deep tendon relexes. D. Decreased bowel
sounds - with correct answers-A) A carotid bruit. Rationale: the carotid artery
(artery to the brain) is narrowed in clients with a brain attack. A bruit is an
abnormal sound heard on auscultation resulting from interference with normal blood
flow. Usually the blood pressure is hypertensive. Initially flaccid paralysis occurs,
resulting in hyporefkexic deep tendon reflexes. Bowel sounds are not indicative of a
brain attack. Which clinical manifestation further supports an assessment of a left
sided brain attack? A) Visual field deficit on the left side. B) Spatial-perceptual
deficits. C) Paresthesia of the left side. D) Global aphasia. D) Global aphasia. - with
,correct answers-D) Global aphasia. Rationale: Global aphasia refers to difficulty
speaking, listening, and understanding, as well as difficulty reading and writing.
Symptoms vary from person to person. Aphasia may occur secondary to any brain
injury involving the left hemisphere. Visual field deficits, spatial-perceptual deficits,
and paresthsia of the left side usually occur with right-sided brain attack. When
preparing a patient for a noncontrast computed tomography (CT) scan STAT, what
nursing intervention should the nurse implement? A) Determine if the client has any
allergies to iodine B) Explain that the client will not be able to move her head
throughout the CT scan. C) Premedicate the client to decrease pain prior to having
the procedure. D) Provide an explanation of relaxation exercises prior to the
procedure. - with correct answers-B) Explain that the client will not be able to move
her head throughout the CT scan. Rationale: Because head motion will distort the
images, Nancy will have to remain still throughout the procedure. Allergies to iodine
is important if contrast dye is being used for the CT scan. Premedicating the client to
decrease pain prior to the procedure is unnecessary because CT scanning is
anoninvasive and painless procedure. Providing an explanation of relaxation exercises
prior to the procedure is a worthwhile intervention to decrease anxiety but is not of
highest priority. A neurologist prescribes a magnetic resonance imaging (MRI) of the
head STAT for a patient. Which data warrants immediate intervention by the nurse
concerning this diagnostic test? A) Elevated blood pressure. B) Allergy to shell fish. C)
Right hip replacement. D) History of atrial fibrillation. - with correct answers-C)
,Right hip replacement. The magnetic field generated by the MRI is so strong that
metal-containing items are strongly attracted to the magnet. Because the hip joint is
made of metal, a lead shield must be used during the procedure. Elevated blood
pressure, an allergy to shell fish, and a history of atrial fibrillation would not affect
the MRI. A client's daughter is sitting by her mother's bedside who was recently
transferred to the Intermediate Care Unit. She states "I don't understand what a
brain attack is. The healthcare provider told me my mother is in serious condition
and they are going to run several tests. I just don't know what is going on. What
happened to my mother?" What is the best response by the nurse? A) "I am sorry,
but according to the Health Insurance Portability and Accounting Act (HIPAA), I
cannot give you any information." B) "Your mother has had a stroke, and the blood
supply to the brain has been blocked." C) "How do you feel about what the healthcare
provider said?" D) "I will call the healthcare provider so he/she can talk to you about
your mother's serious condition." - with correct answers-B) "Your mother has had a
stroke, and the blood supply to the brain has been blocked." Rationale: The nurse can
discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin,
her daughter, Gail, needs sufficient information to make informed decisions. The
nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail.
The nurse should give facts first, and then address her feelings after the information
is provided. What is the normal range for cardiac output? - with correct answers-
The normal range for cardiac output to ensure cerebral blood flow and oxygen
, delivery is 4 to 8 L/min. A client was admitted with the diagnosis of a brain
attack.Their symptoms began 24 hours before being admitted. Why would this client
not be
a candidate for for thrombolytic therapy? - with correct answers-Thrombolytic
therapy is contraindicated in clients with symptom onset longer than 3 hours prior
to admission. This client had symptoms for 24 hours before being brought to the
medical center What are plate guards? - with correct answers-Plate guards prevent
food from being pushed off the plate. Using plate guards and other assistive devices
will encourage independence in a client with a self-care deficit. Which condition is
considered a non-modifiable risk factor for a brain attack? A) High cholesterol levels.
B) Obesity. C) History of atrial fibrillation. D) Advanced age. - with correct answers-
D) Advanced age. Rationale: People over age 55 are a high-risk group for a brain
attack because the incidence of stroke more than doubles in each successive decade of
life. Non-modifiable means the client cannot do anything to change the risk factor.
All the other options are modifiable risk factors. A client is experiencing homonymous
hemianopsia as the result of a brain attack. Which nursing intervention would the
nurse implement to address this condition? A) Turn Nancy every two hours and
perform active range of motion exercises. B) Place the objects Nancy needs for
activities of daily living on the left side of the table. C) Speak slowly and clearly to
assist Nancy in forming sounds to words. D) Request that the dietary department
thicken all liquids on Nancy's meal and snack trays. - with correct answers-B) Place
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