Get Answer: Nurse Performing Neurological Question Guide

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Original Question

A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions? Frowns symmetrically Shrugs his shoulders Identifies a sour taste Sticks his tongue out A nurse in an emergency department is assessing a client who is experiencing heroin intoxication. Which of the following findings should the nurse expect? Increased respiratory rate Rhinorrhea Dilated pupils Hypotension A nurse is preparing to assess a client for pulse deficit. Which of the following actions should the nurse plan to take? Compare the client’s carotid pulse while resting to their carotid pulse after standing for 1 min. After inflation, deflate a blood pressure cuff on the client’s arm while palpating their brachial pulse, Measure the client’s apical pulse while another nurse measures their radial pulse. Assess both of the client’s radial pulses at the same time and compare the quality of pulsations. A public health nurse is teaching a group of new parents about sudden infant death syndrome (SIDS). Which of the following statements by the parents indicates an understanding of the teaching? “My baby will no longer be at risk for SIDS when he reaches 6 months of age.” “I can keep my newborn in bed with me at night to make bottle feeding easier.” “I will avoid giving my baby a pacifier during naptimes.” *I will make sure the mattress in my baby’s crib is firm. A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take? Compare new prescriptions with the list of medications the client reports. Exclude nutritional supplements from the list of medications the client reports Include any adverse effects of the medications the client might develop. Encourage the client to make his own list after he returns to his home. A nurse is preparing to feed a newly admitted client who has dysphagia, Which of the following actions should the nurse plan to take? Sit at or below the client’s eye level during feedings. Talk with the client during her feeding. Instruct the client to lift her chin when swallowing. Discourage the client from coughing during feedings. A newly licensed nurse is unsure If an assigned task is within their scope of practice. Which of the following resources should the nurse consult? Institutional policies and procedures Verbal direction from the nurse manager State Nurse Practice Act Written prescription from the provider A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? Give the dose over 60 min Administer the medication undiluted. Obtain a trough level 30 min after the medication infusion. Inject 1% lidocaine prior to each dose. A nurse is evaluating a client’s ABG results. The results are pH 7.20, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO,- 25 mEq/L. The nurse should identify these values as manifestations of which of the following acid-base imbalances? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching? Blood glucose level less than 60 mg/dL before breakfast HbA1c level less than 7% HbA1c level greater than 8% Blood glucose level greater than 200 mg/dL at bedtime A nurse is caring for a client who has a chest tube drainage device. Which of the following findings indicates to the nurse the presence of an air leak? Serosanguineous fluid in the drainage collection chamber Fluid rising with inspiration and falling with expiration in the water seal chamber Continuous bubbling in the water seal chamber Gentle bubbling in the suction control chamber A nurse working in the postpartum unit is reviewing a client’s new prescription for methylergonovine, The nurse should recognize that which of the following is a contraindication for this medication? Polyuria Hypertension Confusion Chlamydia A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A client who has COPD and a respiratory rate of 44/min A client who has cancer with a sealed implant for radiation therapy A client who is 1 day postoperative following a vertebroplasty A client who is receiving heparin for deep-vein thrombosis A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? Maternal fever Fetal anemia Maternal hypoglycemia Chorioamnionitis A nurse is reviewing a client’s laboratory results prior to surgery. Which of the following findings should the nurse report to the provider? Chioride 100 m€q/L Bicarbonate 26 mEg/L Sodium 160 mEa/L Potassium 3.8 mEg/L A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? Prime IV tubing with 0.9% sodium chloride. Obtain filterless IV tubing. Place the blood in a warmer for 1 hr. Use a 24-gauge IV catheter. A nurse is teaching a client who is at 17 weeks of gestation about undergoing a maternal serum alpha-fetoprotein screening. The nurse should explain that a low level of this marker assists in detecting which of the following disorders? Spina bifida Anencephaly Down syndrome Omphalocele A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port? A butterfly needle A 25-gauge needle A noncoring needle An angiocatheter A nurse is caring for a client who is experiencing status epileptics. Which of the following medications should the nurse expect to administer? Lorazepam Lamotrigine Carbamazepine Clonazepam A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? Metallic taste in mouth Excessive sweating Increased urinary frequency Dry cough A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? Flush the NG tube with 5 mL water. Use a syringe to allow the medications to flow by gravity. Add medication directly to enteral feeding. Dissolve the medications together. A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include? “Use an incentive spirometer every 4 hours.” “Remain on bed rest for 24 hours following the procedure.” “Participate in range-of-motion exercises.” “Place a pillow under your knees while in bed.” A nurse is teaching a parent about safely securing her 3-month-old infant in a car seat. Which of the following images indicates that the parent understands the teaching? Image transcription text Question: 96 of 180 Time Remaining: 00.59:19 PAUSE Pause Remaining: 00:00:53 A nurse is teaching a parent about safely securing her 3-month-old infant in a car seat. Which of the following images indicates that the parent understands the teaching? O A nurse is assigning client care tasks to an assistive personnel (AP) for the upcoming shift. Which of the following tasks is within the AP’s scope of practice? Educate a client on the use of a glucometer. Interpret the client’s need for pain medication. Perform cardiopulmonary resuscitation on a client. Change a sterile dressing on a client’s open incisional wound. A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture? Apply an orthotic to the client’s foot. Position a pillow under the client’s knees. Align a trochanter wedge between the client’s legs. Place a towel roll under the client’s neck. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? Make quarantine preparations for those exposed to anthrax. Vaccinate susceptible children and adults against smallpox. Participate in community drills and mock events Assess types, levels, and scopes of disasters. A nurse is administering medications to a group of clients. Which of the following occurrences requires the completion of an incident report? A client vomits within 20 min of taking morning medications. A client receives his antibiotic 2 hr late A client asks for pain medication 1 hr early, A client requests his statin be administered at 2100.

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