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WorksheetsMod B final 3
Total questions: 85
Worksheet time: 3hrs 50mins
Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication?
Blurred vision
Joint tenderness
Abdominal cramping
Elevated blood pressure
A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately?
The blood pressure is 86/50 mm Hg.
The patient says the knee pain is severe.
The white blood cell count is 11,500/µL.
The patient is taking ibuprofen (Motrin).
Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)?
A 56-yr-old man who has a sedentary office job
A 38-yr-old man who plays on a summer softball team
A 56-yr-old woman who works on an automotive assembly line
A 38-yr-old woman who is newly diagnosed with diabetes mellitus
Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma?
Monitor for difficulty in breathing.
Document the patient’s oral intake.
Check finger strength and movement.
Apply capsaicin (Zostrix) cream to hands.
Which actions will the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur (select all that apply)?
Monitor serum calcium.
Teach about the need for strict bed rest.
Discontinue use of sustained-release opioids.
Support the left leg when repositioning the patient.
Support family and patient as they discuss the prognosis.
Which information will the nurse include when teaching a patient with acute low back pain (select all that apply)?
Sleep in a prone position with the legs extended.
Keep the knees straight when leaning forward to pick something up.
Expect symptoms of acute low back pain to improve in a few weeks.
Avoid activities that require twisting of the back or prolonged sitting.
Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.
During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)?
Sleep disturbances
Multiple tender points
Cardiac palpitations and dizziness
Multijoint inflammation and swelling
Widespread bilateral, burning musculoskeletal pain
A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question?
Administer furosemide (Lasix) 40 mg IV.
Increase normal saline infusion to 250 mL/hr
Give hydrocortisone (Solu-Cortef) 100 mg IV
Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg.
A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which intervention ordered by the health care provider should the nurse question?
Elevate head of bed to 30 degrees.
Infuse normal saline at 250 mL/hr.
Hold nitroprusside if systolic BP is less than 90 mm Hg.
Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?
Inspiratory crackles
Heart rate 45 beats/min
Cool, clammy extremities
Temperature 101.2°F (38.4°C)
An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?
Increase the rate for the dopamine infusion.
Decrease the rate for the nitroglycerin infusion.
Increase the rate for the sodium nitroprusside infusion.
Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.
After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for
furosemide .
nitroglycerin .
norepinephrine .
sodium nitroprusside .
To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?
Auscultate bowel sounds.
Ask the patient about nausea.
Check stools for occult blood.
Palpate for abdominal tenderness.
A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will anticipate an order for which medication?
5% albumin infusion
furosemide (Lasix) IV
epinephrine (Adrenalin) drip
hydrocortisone (Solu-Cortef)
The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation for the patient’s arrival, the nurse will obtain
a dopamine infusion.
a hypothermia blanket.
lactated Ringer’s solution.
two 16-gauge IV catheters.
Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective?
Hemoglobin is within normal limits.
Urine output is 65 mL over the past hour
Central venous pressure (CVP) is normal.
Mean arterial pressure (MAP) is 72 mm Hg.
Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine?
The patient is receiving low dose dopamine.
The patient’s central venous pressure is 3 mm Hg.
The patient is in sinus tachycardia at 120 beats/min.
The patient has had no urine output since being admitted.
A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?
No new heart murmurs
Decreased troponin level
Warm, pink, and dry skin
Blood pressure of 92/40 mm Hg
Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective?
Heart rate
Orientation
Blood pressure
Oxygen saturation
When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education?
Placing the pulse oximeter on the ear for a patient with septic shock
Keeping the head of the bed flat for a patient with hypovolemic shock
Maintaining a cool room temperature for a patient with neurogenic shock
Increasing the nitroprusside infusion rate for a patient with a very high SVR
A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
obtain the blood pressure.
check the level of orientation.
administer supplemental oxygen.
obtain a 12-lead electrocardiogram
Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider?
The patient’s urine output is 18 mL/hr.
The patient is complaining of chest pain.
The patient’s peripheral pulses are weak.
The patient’s heart rate is 110 beats/minute.
After change-of-shift report in the progressive care unit, who should the nurse care for first?
Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases
Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics
Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute
Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg
A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
Administration of 100% O2 by non-rebreather mask
Endotracheal intubation and positive pressure ventilation
Insertion of a mini-tracheostomy with frequent suctionin
Initiation of continuous positive pressure ventilation (CPAP)
The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes, a weak cough effort, and complains of fatigue. Which action should the nurse take next?
Position the patient on the left side.
Assist the patient with staged coughing.
Place a humidifier in the patient’s room.
Schedule a 4-hour rest period for the patient
A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange?
On the left side
On the right side
In the tripod position
In the high-Fowler’s position
When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?
The patient is very somnolent.
The patient complains of weakness.
The patient’s blood pressure is 164/98.
The patient’s oxygen saturation is 90%.
A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving?
gentamicin 60 mg IV
pantoprazole (Protonix) 40 mg IV
sucralfate (Carafate) 1 g per nasogastric tube
methylprednisolone (Solu-Medrol) 60 mg I
A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with
obtaining a ventilation-perfusion scan.
drawing blood for arterial blood gases.
positioning the patient for a chest x-ray.
insertion of a pulmonary artery catheter.
A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?
The patient’s PaO2 is 50 mm Hg and the SaO2 is 88%
The patient has subcutaneous emphysema on the upper thorax.
The patient has bronchial breath sounds in both the lung fields.
The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min.
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?
Elevate head of bed to 30 to 45 degrees.
Give enteral feedings at no more than 10 mL/hr.
Suction the endotracheal tube every 2 to 4 hours.
Limit the use of positive end-expiratory pressure.
A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next?
Increase the tidal volume and respiratory rate.
Decrease the fraction of inspired oxygen (FIO2).
Perform endotracheal suctioning more frequently.
Lower the positive end-expiratory pressure (PEEP).
After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?
A patient with cystic fibrosis who has thick, green-colored sputum
A patient with pneumonia who has crackles bilaterally in the lung bases
A patient with emphysema who has an oxygen saturation of 90% to 92%
A patient with septicemia who has intercostal and suprasternal retractions
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider?
The patient has bibasilar lung crackles.
The patient is sitting in the tripod position.
The patient’s pulse oximetry indicates a 91% O2 saturation.
The patient’s respirations have dropped to 10 breaths/minute.
The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?
The patient’s PaO2 is 45 mm Hg
The patient’s PaCO2 is 33 mm Hg.
The patient’s respirations are shallow.
The patient’s respiratory rate is 32 breaths/min
The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider?
Persistent cough of blood-tinged sputum.
Scattered crackles in the posterior lung bases.
Oxygen saturation 90% on 100% O2 by nonrebreather mask.
Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.
Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit?
Assess breath sounds every hour.
Monitor central venous pressures.
Place patient in the prone position.
Insert an indwelling urinary catheter.
A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of
450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?
O2 saturation of 99%
Heart rate 106 beats/minute
Crackles audible at lung bases
Respiratory rate 22 breaths/minute
During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?
Give the prescribed PRN sedative drug.
Offer reassurance and reorient the patient.
Use pulse oximetry to check the oxygen saturation.
Notify the health care provider about the patient’s status.
A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)?
Prepare to administer atropine IV.
Obtain baseline body temperature.
Infuse large volumes of lactated Ringer’s solution.
Provide high-flow O2 (100%) by nonrebreather mask.
Prepare for emergent intubation and mechanical ventilation.
Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)?
Ambulate postoperative patients as soon as possible after surgery.
Use aseptic technique when manipulating invasive lines or devices.
Remove indwelling urinary catheters as soon as possible after surgery.
Administer prescribed antibiotics within 1 hour for patients with possible sepsis.
Advocate for parenteral nutrition for patients who cannot take in adequate calories.
Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)?
Obtain arterial blood gases daily
Provide a “sedation holiday” daily.
Give prescribed pantoprazole (Protonix).
Elevate the head of the bed to at least 30°.
Provide oral care with chlorhexidine (0.12%) solution daily.
A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/min. The label on the infusion bag states: dobutamine 250 mg in 250 mL of normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many milliliters per hour?
(a)
The health care provider orders the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].)
a. Give vancomycin 1 g IV.
b. Obtain blood and urine cultures
c. Start norepinephrine 0.5 mcg/min.
d. Infuse normal saline 2000 mL over 30 minutes.
e. Titrate oxygen administration to keep O2 saturation above 95%.
(a)
Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?
Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32 breaths/min
Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30 breaths/min
Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min
Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28 breaths/min
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication’s effectiveness?
Hemoglobin and hematocrit
Intracranial pressure
Oxygen saturation
Blood pressure
A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient’s Glasgow Coma Scale score as
11.
13.
9.
15.
A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care
Encourage coughing and deep breathing.
Keep the head of the bed elevated to 30 degrees.
Position the patient with knees and hips flexed.
Cluster nursing interventions to provide rest periods.
A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take?
Prepare the patient for craniotomy.
Administer IV furosemide (Lasix).
Type and crossmatch for blood transfusion.
Initiate high-dose barbiturate therapy.
A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome?
Short-term memory
Muscle coordination
Pupil reaction to light
Glasgow Coma Scale
The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have
impaired judgment.
difficulty swallowing.
expressive aphasia.
right-sided weakness.
After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to
perform range-of-motion (ROM) exercises every 4 hours.
cluster nursing activities to allow longer rest periods.
position the bed flat and log roll to reposition the patient.
turn and reposition the patient side to side every 2 hours.
A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?
Keep the room well-lighted to improve patient orientation.
Encourage family members to remain at the bedside.
Apply soft restraints to protect the patient from injury.
Minimize contact with the patient to decrease sensory input.
The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?
Emphasize the importance of hand washing.
Encourage adolescents and young adults to avoid crowds in the winter.
Support serving healthy nutritional options in the college cafeteria.
Immunize adolescents and college freshman
A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?
The patient receives a regular diet tray.
Staff have entered the patient’s room without a mask.
The bedrails on both sides of the bed are elevated.
Staff have turned off the lights in the patient’s room.
When assessing a 53-yr-old patient with bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention?
The patient’s temperature is 101° F (38.3° C).
The patient has a positive Kernig’s sign.
The patient exhibits nuchal rigidity.
The patient’s blood pressure is 88/42 mm Hg.
Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?
A 55-yr-old patient who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy
A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day
A 35-yr-old patient with intracranial pressure (ICP) monitoring after a head injury
A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis
After evacuation of an epidural hematoma, a patient’s intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?
Mean arterial pressure of 90 mm Hg
Temperature of 101.6° F
Intracranial pressure of 15 mm Hg
Pulse of 102 beats/min
The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?
The staff nurse assesses neurologic status every hour.
The staff nurse elevates the head of the bed to 30 degrees.
The staff nurse administers an analgesic before turning the patient.
The staff nurse suctions the patient routinely every 2 hours.
A 68-yr-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?
Verify Glasgow Coma Scale (GCS) score.
Check oxygen saturation.
Assess pupil reaction to light.
Palpate the head for injuries
A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit?
Check capillary blood glucose level every 6 hours.
Monitor cerebrospinal fluid color and volume hourly.
Document intracranial pressure every hour.
Turn and reposition the patient every 2 hours.
The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires rapid action by the nurse?
The patient complains of a headache.
The apical pulse is slightly irregular.
The blood pressure (BP) increases to 140/62 mm Hg.
The patient is more difficult to arouse.
A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first?
Swab the nasopharyngeal mucosa for cultures.
Give acetaminophen (Tylenol) 650 mg PO
Administer ceftizoxime (Cefizox) 1 g IV.
Use a cooling blanket to lower temperature.
A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question?
Restrict oral fluids to 1000 mL/day.
Administer ceftriaxone (Rocephin) 1 g IV every 12 hours.
Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.
Elevate the head of the bed 20 degrees.
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about
cerebral aneurysm clipping.
heparin intravenous infusion.
oral low-dose aspirin therapy.
tissue plasminogen activator (tPA).
A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?
The patient has atrial fibrillation.
The patient has a history of brief episodes of right-sided hemiplegia.
The patient reports that symptoms began with a severe headache.
The patient has dysphasia.
A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?
Impulsive behavior
Right-sided neglect
Difficulty comprehending instructions
Hyperactive left-sided tendon reflexes
During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have
dysphasia.
poor judgment.
confusion.
visual deficits.
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis
that clopidogrel will dissolve clots in the cerebral arteries.
that clopidogrel will reduce cerebral artery plaque formation.
to monitor and record the blood pressure daily.
to call the health care provider if stools are tarry.
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?
“The obstructing plaque is surgically removed from inside an artery in the neck.”
“A wire is threaded through an artery in the leg to the clots in the carotid artery, and the clots are removed.”
“A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque.”
“The diseased portion of the artery in the brain is replaced with a synthetic graft.”
A female patient who had a stroke 24 hours ago has expressive aphasia. An appropriate nursing intervention to help the patient communicate is to
ask questions that the patient can answer with “yes” or “no.”
have the patient practice her facial and tongue exercises with a mirror.
develop a list of words that the patient can read and practice reciting.
prevent embarrassing the patient by answering for her if she does not respond.
For a patient who had a right hemisphere stroke, the nurse anticipates planning interventions to manage
impaired physical mobility related to right-sided hemiplegia
ineffective coping related to depression and distress about disability.
risk for injury related to denial of deficits and impulsiveness.
impaired verbal communication related to speech-language deficits.
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care?
Approach the patient from the right side.
Teach the patient that the left visual deficit will resolve.
Apply an eye patch to the right eye.
Place needed objects on the patient’s left side.
A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care
Provide a wide variety of food choices.
Teach the patient the “chin-tuck” technique
Assist the patient to eat with the right hand.
Provide oral care before and after meals.
A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient’s wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient?
Disabled family coping related to inadequate understanding by patient’s spouse
Interrupted family processes related to effects of illness of a family member
Impaired nutrition: less than body requirements related to hemiplegia and aphasia
Situational low self-esteem related to increasing dependence on spouse for care
Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program?
Assist the patient onto the bedside commode every 2 hours.
Limit fluid intake to 1200 mL daily to reduce urine volume.
Use an external “condom” catheter to protect the skin and prevent embarrassment.
Perform intermittent catheterization after each voiding to check for residual urine.
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, “I don’t need the aspirin today. I don’t have a fever.” Which action should the nurse take?
Tell the patient that the aspirin is used to prevent a fever
Call the health care provider to clarify the medication order.
Document that the aspirin was refused by the patient.
Explain that the aspirin is ordered to decrease stroke risk.
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about
warfarin (Coumadin).
nimodipine
aspirin .
tPA.
A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should
have the family members leave the patient alone for a few minutes.
explain to the family that depression is normal following a stroke.
use a calm voice to ask the patient to stop the crying behavior.
teach the family that emotional outbursts are common after strokes.
Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address?
The patient’s usual blood pressure (BP) is 170/94 mm Hg.
The patient is 25 lb above the ideal weight.
The patient drinks a glass of red wine with dinner daily.
The patient works at a desk and relaxes by watching television.
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient?
Risk for aspiration related to inability to protect airway
Disturbed sensory perception related to brain injury
Risk for impaired skin integrity related to immobility
Impaired physical mobility related to weakness
Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider?
The patient’s blood pressure (BP) is 90/50 mm Hg.
The patient reports a severe and unrelenting headache.
The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
The patient complains of having a stiff neck.
The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
Administer the prescribed short-acting insulin.
Infuse the prescribed IV metoprolol (Lopressor).
Assess the patient’s gag and cough reflexes.
Determine when the stroke symptoms began.
After receiving change-of-shift report on the following four patients, which patient should the nurse see first?
A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled
A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin)
A 40-yr-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed
The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
There are fine crackles at the lung bases.
The patient has difficulty speaking.
The blood pressure is 144/86 mm Hg.
The pulse rate is 102 beats/min.
