<P> unconscious client who is receiving continuous enteral feedings has a sudd

<Q>An
<TYPE>single</TYPE>
en onset of adventitious breath sounds. Which of the following nursing diagnoses
<MC1>Risk
<MC2>Risk
<MC3>Risk
<MC4>Risk
<F>Rationale:
<CORRECT>1</CORRECT>
is a priority
for Enteral
aspiration</MC1>
fluid
imbalanced
electrolyte
for this
volume
feedings
client?</Q>
nutrition:
imbalance</MC4>
overload</MC2>
increase
lessthe thanrisk
bodyforrequirements</MC3>
aspiration because the clie
nt who is unconscious is unable to protect his or her airway (option 1). Dependi
ng on the client's general medical condition fluid overload is a potential risk
but there is insufficient data to determine if this is relevant for this client
(option 2). Acute illness does increase the metabolic demands of the client but
this is not a priority for this client (option 3). Enteral feedings replace calo
ries, essential nutrients and volume, but in clients who are not receiving suppl
ementalNeed:
Cognitive
Client
Integrated
Content
Strategy:hydration
Area:
Level:
Recall
Process:
Physiological
Fundamentals
Analysis
by
with
Nursing
using
water,
the
Integrity:
Process:
electrolyte
ABCs (airway,
Analysis
Reduction
disturbance
breathing,
of Riskmay
and
Potential
occur
circulation)
(option that
4). air
way is always a priority, especially in a client who is unresponsive and therefo
re unable toLeMone,
Reference: protectP.,the& Burke,
airway.K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>multi</TYPE>
<P>
</P> 1534-1535.</F>
is caring for a client following a motor vehicle accident. During t
he neurological assessment when eliciting the client's response to pain, the cli
ent pulls his arms inward and upward. This position is represents: (Select all t
hat apply.)</Q>
<MC1>Decerebrate
<MC2>Decorticate
<MC3>Injury
<MC4>Injury
<MC5>Injury
<F>Rationale:
<CORRECT>[2,5]</CORRECT>
toDecorticate
theposturing.</MC2>
posturing.</MC1>
brainstem.</MC3>
pons.</MC4>
midbrain.</MC5>
posturing is a late sign of significant deterioration
in neurologic status and is manifested by clients' rigidly flexing their elbows
and wrists (option 2). It can signal injury to the midbrain (option 5). Clients
with significant intracranial injury and edema will frequently exhibit decortica
te posturing first and then decerebrate posturing. Decerebration (option 1) freq
uently precedes brainstem herniation (option 3), while option 4 (pons) is not di
rectly Need:
Cognitive
Client
Integrated
Content
Strategy:
related
Area:
Level:
Read
Process:
Physiological
Adult
toApplication
eachtheanswer
Nursing
Health:
question.
Integrity:
carefully
Process: and
Neurological
Assessment
Physiological
use the process
Adaptation
of elimination. Recall
the positions that occur with deteriorating neurological status and the primary
site of injury
Reference: LeMone,
to make
P., &theBurke,
correct
K. (2008).
selections.<i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 1525-1526.</F>
is admitting a client from the emergency department following a fal
l that resulted in increased intracranial pressure (ICP). The nurse interprets t
hat the client's Glasgow Coma Scale score has improved the most after making whi
ch of the eye
<MC1>Best following
openinglatest
response
assessments?</Q>
5, best motor response 4, best verbal response 8<
<MC2>Best eye opening response 4, best motor response 6, best verbal response 5<
/MC1>
<MC3>Best eye opening response 6, best motor response 5, best verbal response 4<
/MC2>
<MC4>Best eye opening response 3, best motor response 8, best verbal response 6<
/MC3>
<F>Rationale: As outlined in the options, the Glasgow Coma Scale is divided into
<CORRECT>2</CORRECT>
/MC4>
three subsets. Each subset has a range of scores within it, and for the total s
cale the highest possible score is 15 while the lowest is 3. The higher the scor
e, the more optimal should be the recovery. Scores in the "best eye opening resp
onse" category range from spontaneously (4), to speech (3), to pain (2), no resp
onse (1). Scores in the "best motor response" category range from obeys verbal c
ommands (6), localizes pain (5), flexion-withdrawal (4), flexion-abnormal (3), e
xtension-abnormal (2), no response (1). Scores in the "best verbal response" cat
egory range from oriented (5), to confuse conversation (4), inappropriate speech
Cognitive
Client
Integrated
Content
Strategy:
(3), incomprehensible
Need:
Area:
Level:
Identify
Process:
Physiological
Adult
Analysis
the
Nursing
Health:
sounds
categories
Integrity:
Process:
Neurological
(2),that
andAssessment
Physiological
no response
are assessed(1).Adaptation
in a Glasgow Coma Scale and
the values assigned to each type of response. Use the process of elimination to
pick the option that represents the highest level of functioning using numbers t
hat are partLeMone,
Reference: of theP., actual
& Burke,
scale.K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 1513.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse planning care for a client who suffered a cerebrovascular accident
(CVA) with residual dysphagia would write on the care plan to avoid doing which
of the following
<MC1>Feed
<MC2>Give
<MC3>Give
<MC4>Place
<F>Rationale:
<CORRECT>2</CORRECT>
the
foods
foodAclient
with
on
client
during
thethe
slowly</MC1>
thin
unaffected
who
meals?</Q>
consistency
liquids</MC2>
experienced
sideofaofoatmeal</MC3>
CVA
themay
mouth</MC4>
have involvement of the cranial
nerves responsible for chewing and swallowing (dysphagia). The client with dysp
hagia may be started on a diet once the gag and swallow reflexes have returned,
but the food and liquids should be thick enough that the risk of aspiration is m
inimized (option 3). Thin liquids (option 2) should be avoided for this reason.
Because it may take the client longer to chew food, he or she should be fed slow
ly (option 1), and the food should be placed on the unaffected side (option 4) t
o aid in adequate chewing and digestion. In this instance, liquids should be thi
ckened to avoid aspiration. The other options represent helpful actions for the
client Need:
Cognitive
Client
Integrated
Content
Strategy:
with
Area:
Level:
This
Process:
dysphagia.
Physiological
Adult
question
Application
Nursing
Health:
is asking
Integrity:
Process:
Neurological
whatImplementation
Reduction
you wouldof<i>not</i>
Risk Potential
do. Select the distr
acter that LeMone,
Reference: potentially P., &canBurke,
compromise
K. (2008).
the airway.
<i>Medical-surgical nursing: Critical
 thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
</P>p.client
n,
<Q>A
<TYPE>single</TYPE>
<P> 1591.</F>
who experienced a spinal cord injury at the level of T5 rings the ca
ll bell for assistance. Upon entering the room, the nurse finds the client to ha
ve a flushed head and neck, complaining of severe headache, and being diaphoreti
c. The pulse is 47 and BP is 220/114 mmHg. The nurse concludes that immediate tr
eatment is needed
<MC1>Malignant
<MC2>Pulmonary
<MC3>Autonomic
<MC4>Spinal
<F>Rationale:
<CORRECT>3</CORRECT>
shock.</MC4>
Above
hypertension.</MC1>
embolism.</MC2>
dysreflexia.</MC3>
for:</Q>
the level of T6, clients with spinal cord injury are at risk
for autonomic dysreflexia. It is a life-threatening syndrome triggered by a nox
ious stimulus below the level of the injury. This complication is characterized
by severe, throbbing headache, flushing of the face and neck, bradycardia, and s
udden severe hypertension (option 3). The occurrence of these specific symptoms
in association with a spinal cord injury makes malignant hypertension unlikely (
option 1). This symptom cluster is inconsistent with pulmonary emboli, which wou
ld include chest pain, anxiety, and hypoxia (option 2). Spinal shock occurs imme
diately after a spinal cord injury and is characterized by flaccidity and hypote
nsion (option
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
This
Process:
Physiological
4).
Adult
item
Analysis
Nursing
Health:
is directly
Integrity:
Process:
Neurological
relatedAnalysis
Physiological
to the spinalAdaptation
cord injury. Recall the po
ssible complications of this type of injury and compare your mental list to the
symptoms inLeMone,
Reference: the question.
P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.nurse
<Q>A
<TYPE>single</TYPE>
<P>
</P> 1599,is1604.</F>
caring for a client who just experienced a seizure. While doing fo
llow-up documentation, the nurse would include which of the following items in t
he nursingand
<MC1>Amount
<MC2>Unusual
<MC3>Amount
<MC4>Food
<F>Rationale:
<CORRECT>2</CORRECT>
progress
ofsounds
fluid
Documentation
lighting
sleep note?</Q>
or
intake
client
smells
in just
room
hadprior
about when
during
before
seizure
totheonset
seizure</MC2>
theseizure
activity
night
of seizure</MC4>
began</MC1>
prior
includes
to seizure</MC3>
the time the seizure
began, changes in pupil size, eye deviation or nystagmus, body part (s) affecte
d, and the presence of an aura (option 2). An aura is any unusual taste or smell
that may occur prior to seizure activity. The other items listed in options 1,
3, and Need:
Cognitive
Client
Integrated
Content
Strategy:
4Area:
are
Level:
Caring
Process:
unnecessary.
Physiological
Adult
Application
for Nursing
Health:
a clientIntegrity:
Process:
Neurological
with seizures
Implementation
Physiological
requiresAdaptation
knowing what may have cause
d a seizure, warning signs of an approaching seizure (aura), and the physical ma
nifestations of the seizure. Eliminate any distracters that do not answer the qu
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
estion.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp 1584-1549.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> home care nurse is doing an admission assessment on a client discharged f
rom the hospital with a diagnosis of Parkinson's disease. When assessing the cli
ent's neurological
<MC1>Impaired
<MC2>A
<MC3>An
<MC4>Droopy
<F>Rationale:
<CORRECT>2</CORRECT>
shuffling
intention
eyelids.</MC4>
mental
The and
tremor.</MC3>
client
status,
acuity.</MC1>
propulsive
with
theParkinson's
nurse
gait.</MC2>
woulddisease
find a has
client
a gait
with:</Q>
that is characteriz
ed by short, shuffling, accelerating steps (option 2). Impaired mental acuity is
more likely to be found in Alzheimer's disease (option 1). Intention tremor is
common in multiple sclerosis (option 3). Droopy eyelids are a hallmark for myast
henia gravis
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Eliminate
Process:
(option
Physiological
Adult
Analysis
Nursing
Health:
any
4).distracters
Integrity:
Process:that
Neurological Assessment
Reduction
do not reflect
of Risk the
Potential
muscle rigidity and
spastic movements
Reference: LeMone,ofP.,Parkinson's
& Burke, K.disease.
(2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 1636-1637.</F>
is caring for a client with a diagnosis of multiple sclerosis. The
client is concerned about the recurrent exacerbations and fatigue. The nurse sug
gests which
<MC1>Ask
<MC2>Limit
<MC3>Identify
<MC4>Space
<F>Rationale:
<CORRECT>4</CORRECT>
client's
activities
ofMultiple
where
themother's
following
assistive
and
throughout
sclerosis
take
help
interventions
devices
morning
with
theanday
is the
can
andwith
autoimmune
children
beafternoon
toobtained
helpdisease
opportunities
inatnaps</MC2>
the
home?</Q>
at evening</MC1>
reasonable
that
foraffects
rest</MC4>
prices</MC3>
the myeli
n sheath and muscle innervation. It is characterized by remissions and exacerbat
ions, but the exacerbations become longer as the disease progresses. Because it
is a chronic debilitating disease, the goal is to maintain normal family functio
n as long as possible. Option 1 is inconsistent with that goal. Periods of rest
should be arranged around how the client feels rather than schedules. Option 4 d
oes not take into account how the client feels. There is no indication that assi
stive devices
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
This
Process:
Physiological
are
Adult
question
Analysis
needed
Nursing
Health:
isatfocused
Integrity:
this time
Process:
Neurological
onImplementation
(option the
Physiological
helping 3). client
Adaptation
understand how to maint
ain as normal an existence as possible. It encourages the client to respond to t
he cues thatLeMone,
Reference: come from
P., &herBurke,
body.K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 1632.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse reads in an admission note that the physical examination of a clien
t revealed an impairment of cranial nerve II. The nurse instructs ancillary care
givers to dothe
<MC1>Whisper
<MC2>Serve
<MC3>Clear
<MC4>Report
<F>Rationale:
<CORRECT>3</CORRECT>
food
difficulty
which
to
The
client's
theoptic
at ofclient</MC1>
room the
swallowing</MC4>
temperature</MC2>
path
nerve,
following
ofwhich
obstacles</MC3>
when
governs
caring
vision,
for this
is cranial
client?</Q>
nerve II. For th
is client it would be most helpful to clear the area of objects that may not be
perceived by the client but that could lead to falls (option 3). Whispering to t
he client (option 1) is related to cranial nerve VIII, the vestibulocochlear ner
ve. The trigeminal nerve, cranial nerve V, controls sensation on the tongue (opt
ion 2). Cranial nerve IX, glossopharyngeal, innervates the muscles of pharynx ne
eded forNeed:
Cognitive
Client
Integrated
Content
Strategy:Area:
swallowing.
Level:
This
Process:
Safe,
Adult
item
Analysis
Effective
Nursing Neurological
Health:
requires Process:
CaretoEnvironment:
you know
Planning
the names
Management
of the cranial
of Care nerves and the
Reference:
interventions
LeMone,
thatP.,
can&compensate
Burke, K. (2008).
for the <i>Medical-surgical
loss of function of nursing:
that nerve.
Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 1223.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse is providing a client with Bell's palsy with information about medi
cations that might reduce nerve tissue edema. The nurse would explain the action
s and side effects
<MC1>Acetaminophen
<MC2>Ibuprofen
<MC3>Dexamethasone
<MC4>Prednisone
<F>Rationale:
<CORRECT>4</CORRECT>
Bell's
(Advil)</MC2>
(Deltasone)</MC4>
ofpalsy
(Tylenol)</MC1>
(Decadron)</MC3>
whichisofantheinflammatory
following medications?</Q>
process of the fifth cranial nerve
. It causes facial paralysis and can result in corneal abrasions because of an i
nability to close the eye on the affected side. Prednisone is the treatment of c
hoice because it reduces inflammation and edema and can help preserve a signific
ant amount of function; it is also effective against pain when given early in th
e course of treatment (option 4). Ibuprofen (option 2) has weak anti-inflammator
y properties in comparison to prednisone. Decadron (option 3) is the drug of cho
ice in cerebral edema. Acetaminophen (option 1) is an analgesic that works at th
e levelNeed:
Cognitive
Client
Integrated
Content
Strategy:ofTo
Area:
Level:
theselect
Process:
Physiological
Adult
peripheral
Analysis
Nursing
Health:
the best
nerves.
Integrity:
Process:
Neurological
distracter,
Implementation
Pharmacological
eliminate items
andthat
Parenteral
are notTherapies
primarily
related to the inflammatory process. Select the distracter that is used for its
broad anti-inflammatory
Reference: LeMone, P., &properties.
Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 1657-1658.</F>
</P>