SP22 Exam 3 Review

Which patient below is at most risk for a hemorrhagic stroke?

• Which patient below is at most risk for a hemorrhagic stroke?

• A 89 year old female with atherosclerosis.

• A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago.

• A 55 year old female with atrial flutter.

Answer explanation

A hemorrhagic stroke occurs when bleeding in the brain happens due to a break in a blood vessel. Risk factors for a hemorrhagic stroke is uncontrolled hypertension, history of brain aneurysm, old age (due to aging blood vessels.) All the other options are at risk for an ischemic type of stroke.

The RN supervising a senior nursing student is discussing methods for preventing acute kidney injury (AKI). Which points would the RN be sure to include in this discussion? Select all that apply.

• Encourage patients to avoid dehydration by drinking adequate fluids.

• Record intake and output and weigh patients daily.

• Monitor laboratory values that reflect kidney function.

• Immediately report a urine output of less than 2 mL/kg/hr.

• Instruct patients to drink extra fluids during periods of strenuous exercise.

Answer explanation

Instruct patients to drink extra fluids during periods of strenuous exercise.

A patient with Hepatitis A asks you about the treatment options for this condition. Your response is?

• Antiviral medications

• Interferon

• Supportive care

• Hepatitis A vaccine

Answer explanation

There is no current treatment for Hepatitis A but supportive care and rest. Treatments for the other types of Hepatitis such as B, C, and D include antiviral or interferon (mainly the chronic cases) along with rest.

A patient is admitted to the ER with signs and symptoms of painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, bluish discoloration around the belly button is noted. What is this called?

• Grey-Turner’s Sign

• McBurney’s Sign

• Homan’s Sign

• Cullen’s Sign

Answer explanation

Cullen’s sign is a hemorrhagic discoloration of the umbilical area due to intraperitoneal hemorrhage which can predict acute pancreatitis.

A client was brought into the ER for a stroke, but did not receive tissue plasminogen activator (tPA). Which answer below is the best rationale for this?

• Client is already on aspirin

• Client was brought in 4 hours after onset of symptoms

• Client experienced an ischemic stroke

• Client experienced hemorrhagic stroke

Answer explanation

Tissue plasminogen activator (tPA) is a drug given intravenously that dissolves blood clots in ischemic strokes. It is contraindicated in clients having hemorrhagic strokes due to worsening of the bleeding.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

• A blood glucose level of 480 mg/dl

• A right-sided carotid bruit

• A blood pressure of 220/120 mmHg

• Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

Answer explanation

Primary intracerebral hemorrhage from a spontaneous rupture of small vessels accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension.

You’re providing education to a patient with an active Hepatitis B infection. What will you include in their discharge instructions? Select all that apply:

• “Take acetaminophen as needed for pain.”

• “Eat large meals that are spread out through the day.”

• “Follow a diet low in fat and high in carbs.”

• “Do not share toothbrushes, razors, utensils, drinking cups, or any other type of personal hygiene products.”

• “Perform aerobic exercises daily to maintain strength.”

Answer explanation

The patient should NOT take acetaminophen (Tylenol) due to its effective on the liver. The patient should eat small (NOT large), but frequent meals…this may help with the nausea. The patient should rest (not perform aerobic exercises daily) because this will help with liver regeneration.

What action by the nurse should require the most caution when caring for a patient with hepatitis A?

• Inserting an IV

• assessing oral mucus mucosa

• emptying a patient’s bed pan after a bowl movement

• changing the bed linens due to left-over food crumbs on the sheets.

Answer explanation

C is the correct answer. Hep A is transmitted primarily person-to-person by the fecal-oral route. Food can be a method of transmission but needs to be contaminated with fecal matter. Since the transmission of hepatitis A is fecal-oral and not saliva or blood, taking a temperature and changing IV tubing would not spread hepatitis A.

Which is the most common cause of acute encephalitis in the United States?

• Human immunodeficiency virus (HIV)

• Western equine bacteria

• Lyme Disease

• Herpes simplex virus (HSV)

Answer explanation

HSV-1 ( herpes simplex virus) is the most common cause of acute encephalitis in the United States. Fungal infections of the central nervous system occur rarely in healthy people. The Western equine encephalitis virus is one of four types of arboviral encephalitis that occur in North America is one of several fungi that may cause fungal encephalitis. Lyme disease leads to flu like symptoms and starts as a local infection which can systematically spread causing organ issues, however the incidence is rate, HIV leads to autoimmune disorders.

A client newly admitted to an in-patient psychiatric unit is diagnosed with obsessive-compulsive disorder. Which behavioral symptom would the nurse expect to assess?

• The client uses excessive hand washing to relieve anxiety

• The client rates anxiety at 8/10

• The client uses breathing techniques to decrease anxiety

• A client newly admitted to an in-patient psychiatric unit is diagnosed with obsessive-compulsive disorder. Which behavioral symptom would the nurse expect to assess?

Answer explanation

Using excessive hand washing to relieve anxiety is a behavioral symptom exhibited by clients diagnosed with OCD.