Ati lpn med surg exam
Total Questions : 53
Showing 25 questions, Sign in for moreA nurse is caring for a client who recently had a stroke. The client requires assistance with strengthening the affected side. Which of the following referrals should the nurse anticipate the provider to make?
Explanation
A. A respiratory therapist focuses on breathing and airway management, which is not the primary concern for a client needing strengthening after a stroke.
B. An occupational therapist helps clients with daily living activities and fine motor skills, but the focus on strengthening the affected side is more specific to physical therapy.
C. A physical therapist specializes in developing and implementing exercise programs to strengthen muscles and improve mobility, making this the most appropriate referral for the client's needs.
D. A social worker assists with emotional and social needs but would not focus on physical rehabilitation after a stroke.
A nurse is collecting data on a client who has multiple sclerosis. The client reports there are times when the symptoms are active and times when there are no symptoms. Which of the following types of multiple sclerosis does this pattern indicate?
Explanation
A. Primary progressive multiple sclerosis is characterized by a gradual progression of symptoms without relapses, so this does not match the client's pattern.
B. Relapsing-remitting multiple sclerosis is defined by episodes of exacerbation (active symptoms) followed by periods of remission (no symptoms), which aligns with the client's description.
C. Secondary progressive multiple sclerosis follows an initial relapsing-remitting course but leads to a more continuous decline in function, so it does not match the pattern described.
D. Clinically isolating syndrome refers to a single episode of neurological symptoms but does not indicate the pattern of relapses and remissions typical of relapsing-remitting multiple sclerosis.
A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?
Explanation
A. Documenting the findings and continuing the visit does not address the potential seriousness of the weight gain and edema in a patient with heart failure. It is important to act promptly on such findings.
B. Notifying the RN case manager of the change in status is essential because a weight gain of this magnitude, along with generalized edema, may indicate worsening heart failure. This requires a timely assessment and possible adjustment of the treatment plan, including medication and fluid management.
C. While reinforcing the importance of daily weights is beneficial for long-term management, it is not an immediate intervention for the acute change in the patient’s condition.
D. Ensuring the client has been taking their prescribed diuretic is important, but the nurse should first communicate the significant changes to the RN case manager for further evaluation and intervention, as this might require a medication review or adjustment.
A nurse is reinforcing health screening education with a group of clients. The nurse should recognize that which of the following clients has the greatest risk for hypertension?
Explanation
A. While age contributes to hypertension risk, being male and 53 years old does not inherently confer the greatest risk when compared to other factors like ethnicity.
B. The client’s younger age and female gender reduce the overall risk for hypertension compared to other groups.
C. Although people of Asian ethnicity can develop hypertension, their overall risk is lower than that of African Americans.
D. African Americans have a significantly higher risk for hypertension due to a combination of genetic, environmental, and socio-economic factors. This group is known to have a higher prevalence of this condition, often developing it at an earlier age.
A nurse is assisting with the admission of a client who has a subarachnoid hemorrhage and increased intracranial pressure (ICP). Which of the following medications should the nurse anticipate the provider prescribing to decrease ICP?
Explanation
A. Nicardipine is a calcium channel blocker primarily used to manage blood pressure but does not directly reduce ICP.
B. Phenytoin is an anticonvulsant used to prevent seizures, which may occur after a hemorrhage, but it does not address increased ICP.
C. Dopamine is used to increase blood pressure and cardiac output but does not play a role in reducing ICP.
D. Mannitol is an osmotic diuretic that helps decrease ICP by drawing fluid from brain tissue into the bloodstream, thus relieving pressure within the skull. It is the most appropriate intervention for managing increased ICP.
A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply)
Explanation
A. Falls are one of the leading causes of TBIs, especially in older adults and young children.
B. Violence, including assaults or domestic abuse, can result in traumatic brain injuries, often due to blunt trauma to the head.
C. Sports-related injuries, particularly from contact sports like football or boxing, are a well-recognized cause of TBIs.
D. While firefighting can involve physical risks, it is not a direct cause of traumatic brain injuries unless an accident involving the head occurs.
E. Working in a factory, though it may pose various risks, does not typically involve causes directly linked to TBIs unless there is an accidental head injury.
A nurse is assisting with the care of a client who was admitted to the telemetry unit after he experienced chest pain, dyspnea, and diaphoresis. Which of the following ECG findings is a manifestation of acute myocardial infarction?
Explanation
A. A QRS interval of 0.08 second is within the normal range and does not indicate a myocardial infarction.
B. A PR interval of 0.15 second is normal and not indicative of an acute myocardial infarction.
C. ST-segment elevation above the isoelectric line is a key indicator of an acute myocardial infarction (STEMI), signifying myocardial injury.
D. The QT interval being equal to the R to R interval is not a specific indicator of myocardial infarction.
A nurse is reinforcing teaching with a client who has peripheral vascular disease. Which of the following instructions should the nurse include in the teaching?
Explanation
A. Shopping for shoes in the morning is not recommended, as feet tend to swell later in the day, and shoe fitting should account for potential swelling.
B. Incorporating walking into the daily routine helps improve circulation and can aid in managing peripheral vascular disease by promoting blood flow in the legs.
C. Elevating the legs might decrease circulation and is not advised for clients with peripheral vascular disease, as it can reduce blood flow to the extremities.
D. Knee-length stockings can restrict circulation, especially if they are too tight, and should be avoided to promote proper blood flow in clients with this condition.
A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?
Explanation
A. Clients with a basilar skull fracture may experience confusion or memory loss regarding the injury, making them unable to recall how it occurred.
B. Pooling of blood around the eyes, known as "raccoon eyes," is a common sign of a basilar skull fracture.
C. Bruising over the mastoid process (Battle's sign) is another classic sign of a basilar skull fracture, indicating trauma to the base of the skull.
D. Chvostek's sign is associated with hypocalcemia, not basilar skull fractures.
A nurse is collecting data from a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?
Explanation
A. Standing with feet close together when lifting an object does not provide adequate support or balance, increasing the risk of injury. Proper body mechanics involve keeping feet apart for a stable base of support.
B. Putting weight on the heels when moving an object is not advised. Instead, one should keep the weight distributed over the whole foot for stability.
C. When pushing an object, stepping forward with the front foot (rather than moving it backward) helps to maintain balance and applies proper force.
D. Facing the direction of movement is a correct application of proper body mechanics, as it prevents twisting of the spine, reduces strain on the back, and promotes safe movement.
A nurse is assisting with the care of a client following a left femoral cardiac angiography. The nurse should place a sandbag on the client over which of the following areas?
Explanation
A. The right groin area is not the site of the procedure, so placing a sandbag here would not help control bleeding or pressure.
B. The sandbag should be placed over the left groin area where the femoral artery was accessed during the angiography. This helps apply pressure to prevent bleeding from the site and promote clot formation.
C. The right ankle is irrelevant to the procedure and would not require pressure.
D. Similarly, the left ankle has no relation to the femoral angiography site.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
Explanation
A. Autonomic dysreflexia is often triggered by a noxious stimulus, such as bladder distention. Preventing bladder distention by ensuring regular bladder emptying can help prevent the condition.
B. Elevating the client's head is a response to autonomic dysreflexia but does not prevent it from occurring.
C. Providing analgesia for headaches addresses a symptom of autonomic dysreflexia but does not prevent it.
D. Monitoring for elevated blood pressure is important in detecting autonomic dysreflexia once it has started, but it does not prevent it.
A nurse is caring for a client who had a stroke and has dysphagia. The nurse should monitor the client for which of the following complications?
Explanation
A. Dysphagia increases the risk of aspiration, especially when swallowing difficulties are present, making it essential to monitor for signs of aspiration.
B. Gastroesophageal reflux disease (GERD) is not directly related to dysphagia from a stroke.
C. Dumping syndrome occurs after certain types of gastric surgery and is not associated with dysphagia post-stroke.
D. Peptic ulcer disease is not a typical complication of dysphagia following a stroke.
A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
Explanation
A. Pain behind the ear is a common early symptom of Bell's palsy due to inflammation of the facial nerve.
B. Muscle distortion occurs as the facial muscles on the affected side weaken or become paralyzed, leading to an asymmetrical appearance.
C. Facial twitching is not a common manifestation of Bell's palsy; rather, it involves muscle paralysis or weakness.
D. Impaired taste, especially in the anterior two-thirds of the tongue, can occur due to facial nerve involvement.
E. Hearing loss is not typically associated with Bell's palsy; it usually affects facial motorfunction, not auditory function.
A nurse is collecting data on a client who has a heart rate of 56/min. Which of the following findings should the nurse expect?
Explanation
A. A heart rate of 56/min indicates bradycardia, which can reduce cardiac output and lead to dizziness due to decreased cerebral perfusion.
B. A high temperature is not directly associated with bradycardia; fever typically causes tachycardia.
C. Hypoglycemia does not have a direct relationship with bradycardia; it is more commonly associated with symptoms like sweating, confusion, and tremors.
D. Cigarette smoking typically contributes to conditions like tachycardia and vascular constriction, not bradycardia.
A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain. The client states that his chest pain is relieved but now he has a headache. Which of the following responses by the nurse is appropriate?
Explanation
A. The headache is not related to anxiety but is a known side effect of nitroglycerin due to vasodilation.
B. An allergy to nitroglycerin typically presents as a rash or breathing difficulty, not a headache.
C. Nitroglycerin commonly causes headaches due to the dilation of blood vessels in the brain, which usually lessens over time as the body adjusts.
D. A headache does not indicate tolerance to the medication. Tolerance develops when the body becomes less responsive to the medication's effects, which usually involves a reduced effect on chest pain, not the onset of a headache.
A family of a client who has a medical history of stroke, hyperlipidemia, and peptic ulcer disease arrives at the memory care clinic with concerns about their loved one. The family states that the client has experienced worsening memory loss and forgetfulness over the last 6 months. The nurse is concerned the client is experiencing vascular dementia, due to which of the following factors?
Explanation
A. While hyperlipidemia can contribute to vascular damage, it primarily increases the risk of cardiovascular disease and stroke, rather than directly blocking neuron communication to cause dementia.
B. Peptic ulcer disease is not associated with dementia, and the loss of nerve cells in the stomach does not lead to cognitive decline.
C. Peptic ulcer disease does not cause dementia by impacting neuron communication in the stomach.
D. Vascular dementia is often caused by stroke due to reduced blood flow or damage to the blood vessels in the brain, leading to cognitive decline and memory loss.
While admitting a client for a cardiac catheterization, the nurse asks the client about allergies. Which of the following client food allergies should the nurse report to the provider prior to the procedure?
Explanation
A. Gelatin allergies are not directly related to cardiac catheterization procedures, as iodine-based contrast media is typically used.
B. A yeast allergy is unrelated to the contrast dye or materials used in the procedure.
C. Egg allergies may be relevant to some medications or vaccines, but they are not typically a concern in cardiac catheterization.
D. Shellfish allergies are important because clients with shellfish allergies may also react to iodine-based contrast dyes commonly used in cardiac catheterization procedures.
A nurse is contributing to the plan of care for a client who is 24 hr postoperative following an aortic valve replacement with a biologic valve. Which of the following interventions should the nurse include in the plan?
Explanation
A. A cooling blanket is not typically needed unless there is a fever or postoperative temperature dysregulation, which is not a standard intervention in this case.
B. Monitoring daily weight is essential following valve replacement to detect fluid retention or heart failure, which can indicate compromised cardiac function.
C. Opioid medications may be necessary, but they should be prescribed according to the client’s pain needs rather than a routine intervention.
D. PTT levels are usually monitored for clients on anticoagulants, but since the client has a biologic valve, anticoagulation therapy is not always required as with mechanical valves.
A nurse is reinforcing teaching with a client who is taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?
Explanation
A. Benztropine is an anticholinergic agent, which reduces salivation rather than causing excessive salivation.
B. Diarrhea is not a typical side effect of benztropine; constipation is more likely due to its anticholinergic properties.
C. Difficulty voiding is an anticholinergic adverse effect of benztropine, as it can cause urinary retention. The client should report this symptom immediately to prevent complications.
D. Slow pulse is not a common adverse effect of benztropine; it may actually increase heart rate due to its anticholinergic effects.
A nurse is collecting data from a client who has a possible medical diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?
Explanation
A. While travel can expose individuals to various pathogens, Guillain-Barré syndrome (GBS) is more commonly linked to recent infections rather than overseas travel.
B. GBS is often preceded by an acute viral or bacterial infection, particularly an upper respiratory or gastrointestinal infection. This makes it essential for the nurse to inquire about a recent upper respiratory infection.
C. Taking multivitamins does not have a direct connection to the development of GBS.
D. While some vaccines are associated with GBS, the MMR vaccine is not typically a cause of concern in this context.
A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?
Explanation
A. A nonskid mat might be helpful for plate stability, but it does not address the visual deficit related to homonymous hemianopsia.
B. Wide grip utensils are useful for motor difficulties, but the primary issue here is a visual field deficit, not motor impairment.
C. Homonymous hemianopsia results in loss of vision in the same half of the visual field in both eyes. Encouraging the client to turn her head or look for food on the affected side (left side of the tray) can help compensate for the visual loss.
D. While using the right hand may be important after a right-sided stroke, the more pressing issue here is addressing the visual field deficit, not hand preference.
A nurse is assisting with teaching a group of nursing students about the pathophysiology of the spinal cord. Which of the following statements by a nursing student indicates understanding?
Explanation
A. The ascending tract of the spinal cord transmits sensory information to the brain, but it does not process it; processing occurs in the brain itself.
B. This statement accurately describes the function of the descending tracts, which carry motor commands from the central nervous system (CNS) to the muscles, facilitating movement.
C. Sensory receptors are located in various tissues throughout the body, including the skin, not just in the muscles.
D. Motor neurons are not found in the dermal layer; they are located in the spinal cord and the peripheral nervous system, where they innervate muscles.
A nurse is reinforcing teaching with a client who has peripheral arterial disease and reports pain when walking. The nurse should identify that the client can use which of the following herbal supplements to increase pain-free walking distance?
Explanation
A. Black cohosh is typically used for menopausal symptoms and does not have a known effect on walking distance in peripheral arterial disease.
B. Echinacea is primarily used to boost the immune system and treat colds, not for vascular conditions.
C. Saw palmetto is commonly used for benign prostatic hyperplasia (BPH) and does not have evidence supporting its use for peripheral arterial disease.
D. Ginkgo biloba has been shown to improve blood flow and may help increase pain-free walking distance in clients with peripheral arterial disease by enhancing peripheral circulation.
A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan?
Explanation
A. Restraints should not be used routinely for clients with seizure disorders, as they can lead to injury and are not recommended for seizure management.
B. A bite stick is not recommended during a seizure because it can cause injury to the client’s teeth and jaw.
C. Keeping an oxygen setup at the bedside is essential to provide supplemental oxygen if the client experiences difficulty breathing during or after a seizure.
D. Elevating the side rails when the client is in bed helps prevent falls and injuries during a seizure, providing a safer environment.
E. A suction setup at the bedside is important to clear secretions and prevent aspiration during a seizure, especially if the client has impaired swallowing or is at risk for aspiration.
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