Exam #3 PN 2 Ch. 64, 46-48, 41-44

Exam #3 PN 2 Ch. 64, 46-48, 41-44 Know what the left temporal lobe of brain affects as far as the senses

• A nurse prepares to teach a client who has experienced damage to the left

temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client?

• Help the client identify each medication by its color.
• Provide written materials with large print size.
• Sit on the clients right side and speak into the right ear.
• Allow the client to use a white board to ask questions.

ANS: C

The temporal lobe contains the auditory center for sound interpretation. The clients hearing will be impaired in the left ear. The nurse should sit on the clients right side and speak into the right ear. The other interventions do not address the clients left temporal lobe damage.Know what hypoactive deep tendon reflexes affect

• A nurse plans care for a client who has a hypoactive response to a test of deep tendon

reflexes. Which intervention should the nurse include in this clients plan of care?

• Check bath water temperature with a thermometer.
• Provide the client with assistance when ambulating.
• Place elastic support hose on the clients legs.
• Assess the clients feet for wounds each shift.

ANS: B

Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the clients problem.

Know what things can interfere with MRI scans

• A nurse obtains a focused health history for a client who is scheduled for magnetic

resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure?

• Creatine phosphokinase (CPK) of 100 IU/L
• Atrioventricular graft
• Blood urea nitrogen (BUN) of 50 mg/dL
• Internal insulin pump

ANS: D

Metal devices such as internal pumps, pacemakers, and prostheses interfere with the accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. An atrioventricular graft does not contain any metal. CPK and BUN levels have no impact on an MRI procedure.

• After teaching a client who is scheduled for magnetic resonance imaging (MRI), the

nurse assesses the clients understanding. Which client statement indicates a correct understanding of the teaching?

• I must increase my fluids because of the dye used for the MRI.

• My urine will be radioactive so I should not share a bathroom.
• I can return to my usual activities immediately after the MRI.
• My gag reflex will be tested before I can eat or drink anything.

ANS: C

No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not needed and the clients urine would not be radioactive. The procedure does not impact the clients gag reflex.

Know what a single-photon emission computed tomography (SPECT) scan is and if there is any care required afterwards

• A nurse cares for a client who is recovering from a single-photon emission computed

tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client?

• You may return to your previous activity level immediately.
• You are radioactive and must use a private bathroom.
• Frequent assessments of the injection site will be completed.
• We will be monitoring your renal functions closely.

ANS: A

The client may return to his or her previous activity level immediately. Radioisotopes will be eliminated in the urine after SPECT, but no monitoring or special precautions are required.The injection site will not need to be assessed after the procedure is complete.

Know what imitrex is and any side effects associated with it

• A nurse obtains a health history on a client prior to administering prescribed sumatriptan

succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider?

• Bronchial asthma
• Prinzmetals angina
• Diabetes mellitus
• Chronic kidney disease

ANS: B

Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction.Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetals angina. The other conditions would not affect the clients treatment.

What is bacterial meningitis and how is it contracted?

• A nurse obtains a focused health history for a client who is suspected of having bacterial

meningitis. Which question should the nurse ask?

• Do you live in a crowded residence?
• When was your last tetanus vaccination?
• Have you had any viral infections recently?
• Have you traveled out of the country in the last month?

ANS: A

Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks.A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information. The nurse should ask about travel to specific countries in which the disease is common, for example, sub-Saharan Africa.

What are clinical manifestations of Parkinson’s?

• After teaching the wife of a client who has Parkinson disease, the nurse assesses the

wifes understanding. Which statement by the clients wife indicates she correctly understands changes associated with this disease?

• His masklike face makes it difficult to communicate, so I will use a white board.
• He should not socialize outside of the house due to uncontrollable drooling.
• This disease is associated with anxiety causing increased perspiration.
• He may have trouble chewing, so I will offer bite-sized portions.

ANS: D

Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the clients nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the clients masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous systems response.

• A nurse plans care for a client with Parkinson disease. Which intervention should the

nurse include in this clients plan of care?

• Ambulate the client in the hallway twice a day.
• Ensure a fluid intake of at least 3 liters per day.
• Teach the client pursed-lip breathing techniques.
• Keep the head of the bed at 30 degrees or greater.

ANS: D

Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the clients blood. Pursed-lip breathing increases exhalation of carbon dioxide.

Know patient/family teaching for Alzheimer’s and what the medications do

• A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter

asks, Will the medication my mother is taking improve her dementia? How should the nurse respond?

• It will allow your mother to live independently for several more years.
• It is used to halt the advancement of Alzheimers disease but will not cure it.
• It will not improve her dementia but can help control emotional responses.
• It is used to improve short-term memory but will not improve problem solving.

ANS: C

Drug therapy is not effective for treating dementia or halting the advancement of Alzheimers disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations. Medication therapy may not allow the client to safely live independently.

• A nurse assesses a client with Alzheimers disease who is recently admitted to the

hospital. Which psychosocial assessment should the nurse complete?

• Assess religious and spiritual needs while in the hospital.
• Identify the clients ability to perform self-care activities.
• Evaluate the clients reaction to a change of environment.
• Ask the client about relationships with family members.

ANS: C

As Alzheimers disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the clients reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important as assessing the clients reaction to environmental change.

• A nurse witnesses a client with late-stage Alzheimers disease eat breakfast. Afterward

the client states, I am hungry and want breakfast. How should the nurse respond?

• I see you are still hungry. I will get you some toast.
• You ate your breakfast 30 minutes ago.
• It appears you are confused this morning.
• Your family will be here soon. Lets get you dressed.

ANS: A

Use of validation therapy with clients who have Alzheimers disease involves acknowledgment of the clients feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the clients concerns.

• A nurse cares for a client with advanced Alzheimers disease. The clients caregiver

states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond?

• This is a sign of fatigue. The client would benefit from a daily nap.
• Engage the client in scheduled activities throughout the day.
• It sounds like this is difficult for you. I will consult the social worker.
• The provider can prescribe a mild sedative for restlessness.

ANS: B

Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks.