A nurse is caring for a client who was recently admitted to the emergency department following a head on MVA. Client is unresponsive, has spontaneous respirations of 22/min, and a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time?
A) ...
NURS 405: Med Surg II Presentation NCLEX
Questions with correct answers
A nurse is caring for a client who was recently admitted to the
emergency department following a head on MVA. Client is
unresponsive, has spontaneous respirations of 22/min, and a laceration
on his forehead that is bleeding. Which of the following is the priority
nursing action at this time?
A) Keep neck stabilized
B) Insert NG tube
C) Monitor pulse and BP frequently
D) Establish IV access and start fluid replacement Correct Answer-*A*
Keep neck stabilized
Rationale: the greatest risk to the client if permanent damage to the
spinal cord if a cervical injury does exist. The priority nursing
intervention is to keep the neck immobile until damage to the cervical
spine can be ruled out
A client has experienced a left-hemispheric stroke, which of the
following would be an expected finding?
A) Impulse control difficulty
B) Poor judgement
,C) Inability to recognize familiar objects
D) Loss of depth perceptions Correct Answer-*C*
Inability to recognize familiar objects
Rationale: a client who experiences a left-hemispheric stroke will
demonstrate the inability to recognize familiar objects. This is also
known as agnosia
A nurse is caring for a client who a spinal cord injury who reports a
severe headache and is sweating profusely. BP is 220/110 with a heart
rate of 54/min. Which of the following actions should the nurse take
first?
A) Notify provider
B) Sit the client upright in bed
C) Check the urinary catheter for blockage
D) Administer antihypertensive medications Correct Answer-*B*
Sit the client upright in bed
Rationale: The greatest risk to the client is experiencing a
cerebrovascular accident (stroke) secondary to elevated blood pressure.
The first action by the nurse is to elevate the head of the bed until the
client is in an upright position. This will lower the blood pressure
secondary to postural hypotension.
,A client is admitted for treatment of the syndrome of inappropriate
antidiuretic hormone (SIADH). Which nursing intervention is
appropriate?
A) Infusing I.V. fluids rapidly as ordered
B) Encouraging increased oral intake
C) Restricting fluids
D) Administering glucose-containing I.V. fluids as ordered Correct
Answer-*C*
Restricting fluids
Rationale: To reduce water retention in a client with the SIADH, the
nurse should restrict fluids. Administering fluids by any route would
further increase the client's already heightened fluid load
A client with hypothyroidism (myxedema) is receiving levothyroxine
(Synthroid), 25 mcg P.O. daily. Which finding should the nurse
recognize as an adverse effect?
A) Dysuria
B) Leg cramps
C) Tachycardia
D) Blurred vision Correct Answer-*C*
, Tachycardia
Rationale: Levothyroxine, a synthetic thyroid hormone, is given to a
client with hypothyroidism to simulate the effects of thyroxine. Adverse
effects of this agent include tachycardia. The other options aren't
associated with levothyroxine
Which outcome indicates that treatment of a client with diabetes
insipidus has been effective?
A) Fluid intake is less than 2,500 ml/day.
B) Urine output measures more than 200 ml/hour.
C) Blood pressure is 90/50 mm Hg.
D) The heart rate is 126 beats/minute. Correct Answer-*A*
Fluid intake is less than 2,500 ml/day.
Rationale: Diabetes insipidus is characterized by polyuria (up to 8
L/day), constant thirst, and an unusually high oral intake of fluids.
Treatment with the appropriate drug should decrease both oral fluid
intake and urine output. A urine output of 200 ml/hour indicates
continuing polyuria. A blood pressure of 90/50 mm Hg and a heart rate
of 126 beats/minute indicate compensation for the continued fluid
deficit, suggesting that treatment hasn't been effective
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