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NUR421 Exam With Complete Solution
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NUR421 Exam With CompleteSolution
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse
formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the
nurse add to complete the nursing diagnosis statement? Related to visual field deficits
Related to difficulty swallowing
Related to impaired balance
Related to psychomotor seizures - Answer Correct response:
Related to impaired balance
Explanation:
A client with a cerebellar brain tumor may suffer injury from impaired balance as well as
disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and
psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital
lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty
swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal
lobe dysfunction.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 70: Management of
Patients With Oncologic or Degenerative Neurologic Disorders, Localized Symptoms, p.
2094.
Elderly clients who fall are most at risk for which injuries?
Wrist fractures
Humerus fractures
Pelvic fractures
Cervical spine fractures - Answer Correct response:
Pelvic fractures
Explanation:
Elderly clients who fall are most at risk for pelvic and lower extremity fractures. These
injuries are devastating because they can seriously alter an elderly client's lifestyle and
,reduce functional independence. Wrist fractures usually occur with falls on an
outstretched hand or from a direct blow. Such fractures are commonly found in young
men. Humerus fractures and cervical spine fractures aren't age-specific.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 42: Management of
Patients With Musculoskeletal Trauma, Gerontologic Considerations, p. 1203.
Chapter 42: Management of Patients With Musculoskeletal Trauma - Page 1203
A client was undergoing conservative treatment for a herniated nucleus pulposus, at L5
- S1, which was diagnosed by magnetic resonance imaging. Because of increasing
neurologic symptoms, the client undergoes lumbar laminectomy. The nurse should take
which step during the immediate postoperative period?
Discourage the client from doing any range-of-motion (ROM) exercises.
Have the client sit up in a chair as much as possible.
Logroll the client from side to side.
Elevate the head of the bed to 90 degrees. - Answer Correct response:
Logroll the client from side to side.
Explanation:
Logrolling the client maintains alignment of his hips and shoulders and eliminates
twisting in his operative area. The nurse should encourage ROM exercises to maintain
muscle strength. Because of pressure on the operative area, having the client sit up in a
chair or with the head of the bed elevated should be allowed only for short durations.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 70: Management of
Patients With Oncologic or Degenerative Neurologic Disorders, Providing Preoperative
Care, p. 2118.
Chapter 70: Management of Patients With Oncologic or Degenerative Neurologic
Disorders - Page 2118
A client who recently experienced a stroke tells the nurse that he has double vision.
Which nursing intervention is most appropriate?
Encourage the client to close his eyes.
Alternatively patch one eye every 2 hours.
, Turn out the lights in the room.
Instill artificial tears. - Answer Correct response:
Alternatively patch one eye every 2 hours.
Explanation:
Patching one eye at a time relieves diplopia (double vision). Closing the eyes and
making the room dark aren't the most appropriate options because they deprive the
client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 69: Management of
Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies,
Improving Cognitive Function, p. 2077.
Chapter 69: Management of Patients With Neurologic Infections, Autoimmune
Disorders, and Neuropathies - Page 2077
A client is sitting in a chair and begins having a tonic-clonic seizure. The most
appropriate nursing response is to:
hold the client's arm still to keep him from hitting anything.
carefully move the client to a flat surface and turn him on his side.
allow the client to remain in the chair but move all objects out of his way.
place an oral airway in the client's mouth to maintain an open airway. - Answer Correct
response:
carefully move the client to a flat surface and turn him on his side.
Explanation:
When caring for a client experiencing a tonic-clonic seizure, the nurse should help the
client to a flat non-elevated surface and then position him on his side to ensure that he
doesn't aspirate and to protect him from injury. These steps help reduce the risk of
injury from falling or hitting surrounding objects and help establish an open airway. The
client shouldn't be restrained during the seizure. Also, nothing should be placed in his
mouth; anything in the mouth could impair ventilation and damage the inside of the
mouth.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 66: Management of
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