10 Questions | By Santepro | Last updated: Mar 22, 2022 | Total Attempts: 13585
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1.
A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
A.
Is clear and tests negative for glucose
B.
Is grossly bloody in appearance and has a pH of 6
C.
Clumps together on the dressing and has a pH of 7
D.
Separates into concentric rings and test positive of glucose
2.
A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
A.
Strict adherence to a bowel retraining program
B.
Keeping the linen wrinkle-free under the client
C.
Preventing unnecessary pressure on the lower limbs
D.
Limiting bladder catheterization to once every 12 hours
3.
The nurse is caring for the male client who begins to experience seizure activity while in beD. Which of the following actions by the nurse would be contraindicated?
A.
Loosening restrictive clothing
B.
Restraining the client’s limbs
C.
Removing the pillow and raising padded side rails
D.
Positioning the client to side. if possible. with the head flexed forward
4.
The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition:
A.
The client has complete bilateral paralysis of the arms and legs.
B.
The client has weakness on the right side of the body. including the face and tongue.
C.
The client has lost the ability to move the right arm but can walk independently.
D.
The client has lost the ability to move the right arm but can walk independently.
5.
The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated. the nurse avoids doing which of the following?
A.
Giving the client thin liquids
B.
Thickening liquids to the consistency of oatmeal
C.
Placing food on the unaffected side of the mouth
D.
Allowing plenty of time for chewing and swallowing
6.
The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:
A.
Gets angry with family if they interrupt a task
B.
Experiences bouts of depression and irritability
C.
Has difficulty with using modified feeding utensils
D.
Consistently uses adaptive equipment in dressing self
7.
Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client?
A.
Speaking to the client at a slower rate
B.
Allowing plenty of time for the client to respond
C.
Completing the sentences that the client cannot finish
D.
Looking directly at the client during attempts at speech
8.
A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:
A.
Getting too little exercise
B.
Taking excess medication
C.
Omitting doses of medication
D.
Increasing intake of fatty foods
9.
The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:
A.
Eating large. well-balanced meals
B.
Doing muscle-strengthening exercises
C.
Doing all chores early in the day while less fatigued
D.
Taking medications on time to maintain therapeutic blood levels
10.
A male client with Bell’s Palsy asks the nurse what has caused this problem. The nurse’s response is based on an understanding that the cause is:
A.
Unknown. but possibly includes ischemia. viral infection. or an autoimmune problem
B.
Unknown. but possibly includes long-term tissue malnutrition and cellular hypoxia
C.
Primary genetic in origin. triggered by exposure to meningitis
D.
Primarily genetic in origin. triggered by exposure to neurotoxins