Question 1

Marc, a 30-year-old client, is rushed to the emergency department due to mental status changes. Physical examination reveals dilated pupils, tachycardia, and hypertension. The nurse prepares to administer which of the following medications to the client?

Accepted Answer

The client is demonstrating signs of opioid overdose. The effects of opioid overdose are reversed by naloxone. Methadone tapering is administered to manage opioid withdrawal. Bromocriptine is used to manage withdrawal from central nervous stimulants. Flumezanil is administered intravenously to manage central nervous system depressant overdose.

Question 2

Celine, a 45-year-old client, complains of sense of a curtain being drawn in her vision. Flashes of light, floaters, and blurred vision are also reported. Based on these details of information, the client is most likely diagnosed with:

Accepted Answer

The client is most likely diagnosed with retinal detachment. Hyphema is manifested by presence of blood in the anterior chamber. Glaucoma is characterized by gradual loss of peripheral vision. Cataracts are manifested by an opaque, white pupil.

Question 3

A female client is rushed to the emergency department after an accident. The nurse utilizes the Glasgow Coma Scale to assess the client's neurological condition. The client opens her eyes in response to sound, but she does not spontaneously open her eyes. The client is confused in conversation. Pain stimuli are localized, but the client cannot obey simple responses. The client's Glasgow Coma Scale score is:

Accepted Answer

The client's Glasgow Coma Scale score is 12. Eye-opening in response to sound = 3; verbal response = 4; and motor response = 5. The scale assesses a client's neurological condition based on responsiveness to motor, verbal, and sensory function.

Question 4

A client who was admitted to the neurology unit has injuries above T6. A urinary catheter is in place. After the morning care, the client begins to complain of severe headache. Physical examination reveals flushing of face and neck, bradycardia, hypertension, dilated pupils, and piloerection. Which of the following is an appropriate intervention for the client?

Accepted Answer

The most appropriate intervention is to check for kinks in the urinary tubing. A client with injuries above T6 is at risk for autonomic dysreflexia, which is manifested by flushing of face and neck, bradycardia, hypertension, dilated pupils, and piloerection. Autonomic dysreflexia is commonly caused by bladder distention and impacted rectum. The client should be in high-Fowler's position. Vital signs are checked every 15 minutes.

Question 5

An 18-year-old male was admitted to the unit after sustaining a head trauma during a football game. The nurse caring for the client recognizes the client's greater risk for increased intracranial pressure. Which of the following findings should alert the nurse as it is the earliest indication of increasing intracranial pressure?

Accepted Answer

A change in the level of consciousness is the most sensitive and earliest indication of increasing intracranial pressure. Bradycardia, increased systolic blood pressure, and widened pulse pressure are late signs of increased intracranial pressure.

Question 6

Michelle is a 37-year-old female experiencing severe diarrhea that contains blood and mucus. The client is admitted to the facility for treatment. After a series of tests, the client is diagnosed with ulcerative colitis. The nurse caring for the client implements which of the following as the priority intervention during the acute phase of ulcerative colitis?

Accepted Answer

The priority intervention during the acute phase of ulcerative colitis is maintaining the NPO status. Bowel rest prevents the secretion of highly corrosive gastrointestinal fluids, decreasing the severity of pain and other symptoms. A clear liquid diet is maintained after the bowel rest. Restricting the client's activity can decrease the symptoms by reducing intestinal activity, but it is not the priority action. The most important step is to prevent secretions that can aggravate the condition. The client may consume bulk-forming agents between episodes.

Question 7

Which of the following infants should the nurse see first?

Accepted Answer

The normal apical rate for newborns is between 120 and160 beats per minute when sleeping and around 180 beats per minute when crying. A bulging fontanel caused by crying is a common finding in infants. It becomes a concern if the fontanel does not return to normal when the infant is already calm. Parchment-like skin is usually seen in babies born after 42 weeks of gestation. Brief episodes of apnea during sleep, lasting no more than 20 seconds, are usually observed in newborns. The respiratory pattern in newborns is caused by immaturity of the part of the brain that controls breathing.

Question 8

A client diagnosed with severe anemia is receiving packed red blood cells. Around fifteenminutes after the infusion is started, the client complains of itching, lower back pain, shortness of breath, and development of hives on the chest area. The client has chills and fever. Which of the following should the nurse do first?

Accepted Answer

Fever, chills, itching, lower back pain, and development of hives minutes after infusing the packed red blood cells all suggest that the client is having a transfusion reaction. The best nursing action is to immediately stop the infusion before calling the physician for an order of antihistamine.

Question 9

Which of these clients should the nurse assess first?

Accepted Answer

A bulging and tensed anterior fontanel is indicative of increased intracranial pressure, a serious medical problem. Increased pressure can damage the brain or the spinal cord; therefore, it should be the nurse's first priority. The child on a gluten-restricted diet would have adjusted to the diet and the child with an episode of seizure would have to be closely monitored. Though it is important to give preoperative preparations to the 10-year-old for a tonsillectomy, it does not take priority over an infant with increased ICP.

Question 10

The nurse receives the client assignment for the day. After making her rounds, which of the following clients would be nurse's first priority?

Accepted Answer

A nurse should first see the least stable client; therefore, the client with fever and diaphoresis must be the nurse's first priority. The client scheduled for a diagnostic procedure in 4 hours and the client who needs assistance with ambulation are both stable and do not have priority needs. It is best that the nurse see the postoperative client when the medication has already taken effect.

Question 11

A nurse in the emergency room receives a female client with critically lacerated wrists. The initial action of the nurse is to:

Accepted Answer

The initial nursing action is to examine the wound and provide appropriate treatment. Administration of any medication, including tetanus toxoid, is not done without a physician's order. Deep breathing is recommended, but it is not a priority.

Question 12

An 11-year-old girl had a brain tumor resection. After the procedure, the child starts to demonstrate difficulty with her fine motor skills and is now unable write. The nurse refers the child to which health care professional?

Accepted Answer

The nurse refers the child to an occupational therapist who has the necessary skills to address the needs of the child. Occupational therapists assist clients with their daily activities, whereas physical therapists assist their clients to regain strength, mobility, and fitness. Speech therapists help clients with speaking and swallowing difficulties, whereas nutritionists plan food and nutrition programs and supervise meal preparations.

Question 13

A nurse would see which of the following clients first?

Accepted Answer

It is important that the nurse see the client with sickle crisis with an infiltrated IV first. Rehydration is vital to reduce pain and blood clotting. The other clients are not the nurse's first priority.

Question 14

A nurse received four messages while she was out of the clinic. The nurse would call which of the following clients first?

Accepted Answer

Severe pain, pallor, paralysis, paresthesia, or loss of palpable pulses on the casted leg suggests neurovascular compromise, which requires immediate assessment and treatment. The other clients are not a priority.

Question 15

A nurse just received the report from the previous shift. Which of the following clients would the nurse see first?

Accepted Answer

Tumor lysis syndrome is a medical emergency characterized by electrolyte imbalances. The client is at risk for renal failure; therefore, this patientmust be the RN's first priority. The other clients are followed up with, but they are not a priority.

Question 16

The nurse is planning care for an eighty-two-year old confused client with a nursing diagnosis of altered mental status. Which of the following interventions should the nurse include in her plan of care?

Accepted Answer

A confused elderly client must be frequently reoriented, focusing more on general issues or information, such as the current month, year, and city. Keeping the client's room lighted at all times can have a negative effect on the normal circadian rhythm. A bedside commode ensures safety, but it does not address the nursing diagnosis. Leaving the television on can leave the client more confused, as television programs might be perceived as real.

Question 17

A nurse is alerted when she finds a 10-year-old child having seizures. Which of the following nursing actions is most appropriate?

Accepted Answer

Padding the side rails can protect the child from injuries. A tongue blade should not be inserted during the seizure, as it can chip the child's teeth, fracture his jaws, stimulate the gag reflex, or cause aspiration. Restraining the child or holding him down is not attempted because tactile stimulation can exacerbate the seizure activity.

Question 18

A nurse is receiving a ten-year-old child from the post-anesthesia care unit who has just undergone a tonsillectomy. The nurse ensures the child's safety by placing the child in which of the following positions?

Accepted Answer

During the postoperative period, the nurse should turn the child to the side-lying position to drain the secretions from the mouth. This position reduces the risk for aspiration.

Question 19

A nurse arrives at an emergency scene. The nurse determines that which of the following clients is least in need of an emergency assessment?

Accepted Answer

A client with an old injury is least likely to require an emergency assessment. New and life-threatening conditions are prioritized.

Question 20

A three-day-old full-term infant is observed with yellowish skin and sclera. Laboratory examination reveals a total serum bilirubin level of 15 mg/dl. The nurse determines that these symptoms suggest:

Accepted Answer

Normal physiological jaundice usually occurs after the first 24 hours of life and usually peaks between thethird and fifthday. Pathological jaundice in full-term babies is characterized by an increase in total serum bilirubin within the first 24 hours. It is commonly caused by an incompatibility of major blood groups or ABO. Breastfeeding jaundice occurs within the first week and peaks within two to three weeks of age.

Quiz 1: Changes in Health