Principles MedSurg2 Jersey College Questions & Answers 100% Correct!!
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Principles MedSurg2 Jersey College
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Principles MedSurg2 Jersey College
Parkinson's Disease - ANSWER-A client has muscle rigidity with passive range of motion, a tremor that is present at rest and absent while feeding himself, and has slow motor movements. These clinical manifestations are consistent with which disorder?
NMS - ANSWER-A nurse is caring for a client w...
Principles MedSurg2
Jersey College
Questions & Answers
100% Correct!!
Parkinson's Disease - ANSWER-A client has muscle rigidity with passive range of motion, a tremor
that is present at rest and absent while feeding himself, and has slow motor movements. These
clinical manifestations are consistent with which disorder?
NMS - ANSWER-A nurse is caring for a client with Parkinson's disease who takes levodopa routinely.
He has a temperature of 103 degrees Fahrenheit, increased muscle rigidity, and a decreased level of
consciousness. Which of the following is true? These clinical manifestations are consistent with
ALS - ANSWER-A client is admitted for a complaint of lower extremities weakness which has
progressively gotten worse over the last 2 months. When assessing the client the nurse observes
lower extremity muscle wasting and 4+ patellar reflexes bilaterally. These clinical manifestations are
consistent with which disorder?
hx of prostate cancer - ANSWER-A male client with a history of prostate cancer is admitted for
severe, uncontrolled pain in his lumbar back. He denies any recent injury but doesn't want to get out
of bed. When reporting these findings to the primary care provider, the nurse would emphasize
which finding?
Headache and profuse facial diaphoresis - ANSWER-A nurse is preparing to complete the discharge
teaching for a client with a spinal cord injury. Which of the following clinical manifestations should
the nurse educate the client about when discussing reasons to seek emergent medical care?
,Heart rate of 50, blood pressure of 80/40 mmHg and a low cardiac output - ANSWER-A nurse is
caring for a client with an acute spinal cord injury. The unlicensed assistive personnel reports that the
client is unresponsive. Which of the following clinical manifestations suggests that the client is
experiencing neurogenic shock?
remove and apply foot splints q2h - ANSWER-Which of the following nursing interventions is
appropriate for the nurse to implement to prevent complications related to immobility in an
unconscious client?
1. Crackles and wheezes
2. Sodium 120 mg/dL
3. Excessive weight gain - ANSWER-The nurse is caring for a client with bronchogenic carcinoma. The
client develops syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following
assessment findings is consistent with this condition? Select all that apply.
encephalitis - ANSWER-The nurse is caring for a pregnant client with active genital herpes simplex 2
infection. During the delivery process the neonate is at the greatest risk for developing which of the
following disorders?
The client requires ventilatory support - ANSWER-An otherwise healthy client with a severe closed
head injury is brought to the emergency department. Assessment findings reveal that the client is
brain dead. The nurse understands that brain death means which of the following?
immobility - ANSWER-A client is brought to the emergency department by ambulance and is
unconscious. The nurse understands that the level of consciousness can change for all of the
following reasons except?
seizure activity - ANSWER-A client with a history of alcohol abuse is admitted for alcohol withdrawal.
The nurse should observe the client closely for which of the following complications?
Cerebral spinal fluid production is decreased to help compensate for the increased volume. -
ANSWER-When caring for a client with increased intracranial pressure, the nurse knows that which of
the following is true?
Massaging the lower extremities - ANSWER-When caring for a client who has an acute deep vein
thrombosis of the right leg and is being treated with heparin, the nurse avoids performing which of
the following actions?
,1. Keep the head of the bed elevated at 30 degrees
2. Maintain the cuff pressure at 15 mmH - ANSWER-The nurse is caring for a client on a mechanical
ventilator. The client is receiving continuous feeding via a gastrostomy tube. Which of the following
actions should the nurse take to prevent complications? Select all that apply.
Oculomotor nerve compression - ANSWER-An unconscious client with a closed head injury has a
dilated left pupil that is slow to respond to light. Which of the following abnormalities best explain
the client's clinical manifestations?
Check the client's visual acuity - ANSWER-A client was recently admitted to the emergency
department after falling down a flight of stairs. The client is complaining of nausea along with a
headache and requests pain medication. The nurse observes that the client is restless. Which of the
following actions by the nurse is a priority?
Ineffective cerebral tissue perfusion related to increased intracranial pressure. - ANSWER-A nurse is
caring for a client with a closed head injury. The client has become increasingly lethargic, complains
of a headache, and clears his throat spontaneously. His BP is 120/70, pulse is 80, respirations are 18
and his oxygen saturation is 98%. Which of the following nursing diagnoses is appropriate?
dehydration - ANSWER-A 79 year old female client with nausea and vomiting has a temperature of
99.5 degrees fahrenheit. Which of the following is the most likely cause of the client's abnormal
temperature?
pt voids q4-6h - ANSWER-The nurse is caring for a client who has a hyperreflexic bladder. Which of
the following assessment findings suggest that treatment with an antispasmodic was effective?
respiratory failure - ANSWER-Clients with a closed head injury, a subdural hematoma, an epidural
hematoma or a subarachnoid hemorrhage are at an increased risk for which of the following
complications?
edema - ANSWER-A client with a brain tumor is receiving dexamethasone (decadron). The nurse
should monitor the client for which of the following clinical manifestations?
'Because of your recent transplant, I would consult your physician about the flu vaccination.' -
ANSWER-A client who recently had a kidney transplant is inquiring about having the nasal influenza
vaccination for the upcoming flu season. Which response by the nurse is most appropriate?
, This is a sign of severe neurologic damage. - ANSWER-A nurse is caring for an unconscious client who
extends his elbows, pronates his arms, flexes his wrists and points his toes. Which of the following is
true?
Flaccid paralysis - ANSWER-When caring for a client who sustained a lower motor neuron injury and
is paralyzed from the waist down, the nurse anticipates which of the following findings?
The client is somewhat obtunded - ANSWER-The nurse is caring for a client with a closed head injury.
The client is lethargic and complains of a headache. Which of the following clinical manifestations
suggests a worsening head injury.
cerebral bleed - ANSWER-The nurse is caring for a client with a cerebral arteriovenous malformation.
The nurse knows that the client is at an increased risk for which of the following disorders?
Administering intravenous Dextrose 5% in Water - ANSWER-The charge nurse observes the RN caring
for a client with increased intracranial pressure. Which of the following actions performed by the RN
requires the charge nurse to intervene?
Dysarthria Treatment - ANSWER-Acute ischemic strokes on the left side put the client at risk for
which of the following clinical manifestations?
left frontal lobe - ANSWER-A client is admitted with an acute ischemic stroke. The nurse notes that
the client is aphasic and is slow and cautious to respond. The client also has weakness to the right
hand. The clinical manifestations are consistent with an infarct in which part of the brain?
1. deficits in depth perception
2. impulsive behavior
3. increased distractibility
4. lack or awareness of deficits - ANSWER-right hemispheric strokes are marked by ? (4)
muscle spasms - ANSWER-A client has a history of multiple sclerosis. The nurse understands the
effect that lesions to the upper motor neurons have and anticipates which of the following findings?
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