Exam II Adult Health

Which of the following would the nurse find in a client with an increasing ICP?

(select all that apply)

• Nausea

• Alert

• Slurred speech

• Nuchal rigidity

• Pupillary changes

Answer explanation

Elevation of intracranial pressure clinical manifestations include pupil changes, HA, slurred speech and disorientation/confusion

Which of the following interventions should the nurse perform when caring for a client with seizures?

(select all that apply)

• Have suction ready

• Have oxygen set up

• Have restraints at the bedside

• Keep the bed in low position

• Have tongue depressor at the bedside

Which of the following foods would be the best choice for a client with cirrhosis?

• Potato chips

• Ham and cheese

• Vanilla milk shake

• Salted peanuts

Answer explanation

Avoid Na! Clients have protein deficiency

The best diet for a client with acute pancreatitis is____________

Answer explanation

Nothing is recommended to minimize pancreatic stimulation

A client is post operative cholecystectomy. What is the priority?

• Check surgery site

• Vital signs

• Auscultate bowel sounds

• Administer pain medication

Answer explanation

All are correct but the priority is VS/02 sats.

The nurse is teaching a client after a mastectomy. What interventions should the nurse include in the plan of care?

(select all that apply)

• Do exercises until discomfort intolerable

• Participate in ADL's

• No heavy lifting over 10lbs for a month

• Exercise slowly

• Exercise to full ROM

Answer explanation

Exercise is to retain range of motion (ROM), weight restrictions, do exercises slowly and participate in activities of daily living

A client is pancytopenic. What are precautions the nurse should implement?

(select all that apply)

• Hold pressure on injection sites

• Frequent handwashing

• Monitor temperature

• Family grieving sessions

• Recommend electric shaver

The client is taking carbidopa/levodopa for PD. What is a contraindication of this medication?

• Glaucoma

• Tremors

• Hypertension

• Immobility

What are the risks for ovarian cancer?

(select all that apply)

• Early pregnancy

• HRT

• Family history

• Late menopause

• Missed menstrual cyles

Match the following

• ischemic CVA

• cerebral aneurysm

• Ischemic stroke

• thrombocytopenia

• ischemic stroke

• smoking

• hemorrhagic stroke

• atrial fibrillation

• hemorrhagic CVA

• diabetes