Exam (elaborations)
Critical Care Exam #3 – Questions And Answers
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Critical Care Exam #3 – Questions And Answers
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Critical Care Exam #3 – Questions And AnswersA client is in the emergency department reporting a brief episode during
which he was dizzy, unable to speak, and felt like his legs were very heavy.
Currently the client's neurologic examination is normal. About what drug
should the nurse plan to teach the client?
a. Alteplase (Activase)
b. Clopidogrel (Plavix)
c. Heparin sodium
d. Mannitol (Osmitrol) ✔️Ans - B. Clopidogrel
A nurse is preparing a client for discharge from the emergency department
after experiencing a transient ischemic attack (TIA). Before discharge, which
factor would the nurse identify as placing the client at high risk for a stroke?
a. Age greater than or equal to 75
b. Blood pressure greater than or equal to 160/95
c. Unilateral weakness during a TIA
D. TIA symptoms lasting less than a minute ✔️Ans - C. unilateral weakness
during a TIA
The nurse is taking a history from a daughter about her father's onset of
stroke signs and symptoms. Which statement by the daughter indicates that
the client likely had an embolic stroke?
a. Client's symptoms occurred slowly over several hours
b. Client because increasingly lethargic and drowsy
c. Client reported severe headache before other symptoms
d. Client has a long history of atrial fibrillation ✔️Ans - Client has a long
history of atrial fibrillation
A client is admitted with a sudden decline in level of consciousness. What is
the nursing action at this time?
a. Assess the client for hypoglycemia and hypoxia
b. Place the client on his or her side
c. Prepare for administration of a fibrinolytic agent
d. Start a continous IV heparin sodium infusion ✔️Ans - a. Assess the client
for hypoglycemia and hypoxia
,The nurse is teaching assistive personnel (AP) about care for a male client
diagnosed with acute ischemic stroke and left-sided weakness. Which
statement by the AP indicates understanding of the nurse's teaching?
a. "I will use "yes" or "no" questiosn when communicating with the client"
b. "I will remind the client frequently to not get out of bed without help"
c. "I will offer a urinal every hour to the client due to incontinece"
d. "I will feed the client slowly using a soft or pureed food" ✔️Ans - b. "I will
remind the client frequently to not get out of bed without help"
A nurse receives a hand-off report on a female client who had a left-sided
stroke with homonymous hemianopsia. What action by the nurse is most
appropriate for this client?
a. Assess for bladder and bowel retention and/or incontinence
b. Listen to teh client's lungs after eating or drinking for diminished breath
sounds
c. Support the client's left side when sitting in a chair or in bed
d. Remind the client to mover her head from side to side to increase her visual
field. ✔️Ans - d. Remind the client to mover her head from side to side to
increase her visual field.
A client with a stroke is being evaluated for fibrinolytic therapy. What
information from the client or family is most important for the nurse to
obtain?
a. Loss of bladder control
b. Other medical conditions
c. Progession of symptoms
d. Time of symptom onset ✔️Ans - d. Time of symptom onset
The nurse is preparing to adminster IV atleplase for a client diagnosed with an
acute ischemic stroke. Which statement is correct about the administration of
this drug?
a. The recommended time for drug adminstration is within 90 minutes after
admission to the emergency department.
b. The drug is given in a bolus over the first 3 minutes followed by a continous
infusion
c. The maximum dosage of the drug, including the bolus, is 120 mg
intravenously
d. The drug is not given to clients who are alr ✔️Ans - d. The drug is not
given to clients who are already on anticoagulant or antiplatelet therapy
, A client is receiving IV alteplase and reports a sudden severe headache. What
is the nurse's first action?
a. Perform a comprehensive pain assessment
b. Discontinue the infusion of the drug
c. Conduct a neurologic assessment
d. Administer an antihypertensive drug ✔️Ans - b. Discontinue the infusion
of the drug
A client experiences impaired swallowing after a stroke and has worked with
speech-language pathology on eating. What nursing assessment best indicates
the expected outcome for this problem has been met?
a. Chooses preferred items from the menu
b. Eats 75 to 100% of all meals and snacks
c. Has clear lung sounds on auscultation
d. Gains 2 lb (1 kg) after 1 week ✔️Ans - c. Has clear lung sounds on
auscultation
A male client was admitted with a left-sided stroke this morning. The assistive
personnel asks about meeting the client's nutritional needs. Which response
by the nurse is appropriate?
a. "He is NPO until the speech-language pathologist performs a swallowing
evaluation."
b. "You may give him a full-liquid diet, but please avoid solid foods until he
gets stronger."
c. "Just be sure to add some thickener in his liquids to prevent choking and
aspiration."
d. "Be sure to sit him up when you are feed ✔️Ans - a. "He is NPO until the
speech-language pathologist performs a swallowing evaluation."
A client is admitted with a diagnosis of cerebellar stroke. What intervention is
most appropriate to include on the client's plan of care?
a. Ambulate only with a gait belt
b. Encourage double swallowing
c. Monitor lung sounds after eating
d. Perform postvoid residuals ✔️Ans - a. Ambulate only with a gail belt
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