Exam 3 review

1.     The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis?

• Muscle atrophy and flaccidity.

• Fatigue and malnutrition.

• Slurred speech and dysphagia.

• Weakness and paralysis.

Answer explanation

ALS results from the degeneration and demyelination of motor neurons in the spinal cord, which results in paralysis and weakness of the muscles.

 

 

The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention?

• The client has scanning speech and diplopia.

• The client has dysarthria and scotomas.

• The client has muscle weakness and spasticity.

• The client has a congested cough and dysphagia.

Answer explanation

Dysphagia is a common problem of clients diagnosed with multiple sclerosis,and this places the client at risk for aspiration pneumonia.

1.     When providing care for a patient with ALS, the nurse recognizes what as one of the most distressing problems experienced by the patient?

• Painful spasticity of the face and extremities

• Retention of cognitive function with total degeneration of motor function

• Uncontrollable writhing and twisting movements of the face, limbs, and body

• Knowledge that there is a 50% chance the disease has been passed to any offspring

   

1.     When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should

• assess for the presence of chest pain.

• inquire about urinary tract problems.

• inspect the skin for rashes or discoloration

• ask the patient about any increase in libido.

1.      A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." The nurse will document this as

• somatic pain

• referred pain

• neuropathic pain

• breakthrough pain

1.     When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication?

• The patient has cramping abdominal pain.

• The patient becomes restless and agitated.

• The patient has not voided for over 10 hours.

• The patient complains of a "pounding" headache.

1.     When the nurse visits a hospice patient, the patient has a respiratory rate of 8 breaths/minute and complains of severe pain. Which action is best for the nurse to take?

• Inform the patient that increasing the morphine will cause the respiratory drive to fail.

• Administer a nonopioid analgesic, such as a nonsteroidal anti-inflammatory drug (NSAID), to improve patient pain control.

• Tell the patient that additional morphine can be administered when the respirations are 12.

• Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief.

   

Which of these prescribed therapies should the nurse use first when caring for a patient with cancer pain that the patient describes as at "level 8 (0 to 10 scale), deep, and aching."

• fentanyl (Duragesic) patch

• ketorolac (Toradol) tablets

• hydromorphone (Dilaudid) IV

•     acetaminophen (Tylenol) suppository

The nurse is conducting a dietary assesment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?The nurse is conducting a dietary assesment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?

• Vitamin A

• vitamin B12

• Vitamin C

• Vitamin E

A client with HTN has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?

• tomato soup

• boiled shrimp

• instant oatmeal

• summer squash