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Test 2-revised- SashaMiladyMari Study Group

Quiz by ShoNuff O

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54 questions
Show answers
  • Q1
    A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140mcmol/L). Which finding would be expected as a result of this laboratory result?
    Tachycardia
    Slurred speech
    Hypotension
    No abnormal Finding
    300s
  • Q2
    Carbamazepine (Tegretol) is prescribed for a client in the management of generalized tonic-clonic seizures. The nurse is providing instructions to the client regarding the side and adverse effects of the medication and tells the client to inform the health care provider if which occurs?
    Drowsiness
    Dizziness
    Nausea
    Sore throat
    300s
  • Q3
    The nurse is in the room with a client when a seizure begins. The client’s entire body becomes rigid, and the muscles in all four extremities alternate between relaxation and contraction. Following the seizure, which type of seizure should the nurse document that the client had experienced?
    Complex partial seizure
    Tonic-clonic seizure
    Partial seizure
    Absence seizure
    300s
  • Q4
    A client begins to experience a tonic-clonic seizure. Which actions should the nurse take? Select all that apply. 1. Restrain the client. 2. Turn the client to the side. 3. Maintain the client’s airway. 4. Place a padded tongue blade into the client’s mouth. 5. Loosen any restrictive clothing that the client is wearing. 6. Protect the client from injury, and guide the client’s movements.
    1,3,6
    2,3,5,6
    1,3,4,5
    2,5,6
    300s
  • Q5
    The nurse receives a telephone call from the emergency department and is told that a child with a diagnosis of tonic-clonic seizures will be admitted to the pediatric unit. The nurse prepares for the admission of the child and instructs the unlicensed assistive personnel to place which items at the bedside?
    A tracheotomy set and oxygen
    An emergency cart and laryngoscope
    An endotracheal tube and an airway
    Suction apparatus and oxygen
    300s
  • Q6
    The nurse is preparing a plan regarding home care instructions for the parents of a child with generalized tonic-clonic seizures who is being treated with oral phenytoin (Dilantin). Which instruction should the nurse include in the plan?
    3. Administer the Check the child’s blood pressure before the administration of the medication.
    Administer the medication 1 hour before food intake.
    Monitor the child’s intake and output daily.
    Provide oral hygiene, especially care of the gums.
    300s
  • Q7
    The nurse is reviewing the results of a client’s phenytoin (Dilantin) level that was drawn that morning. What result indicates the client has reached a therapeutic drug level? 1. 3 mcg/mL 2. 8 mcg/mL 3. 15 mcg/mL 4. 24 mcg/mL
    4
    3
    1
    2
    300s
  • Q8
    The nurse is planning care for a client with a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)? 1. Assist the client to develop a daily bowel routine to prevent constipation. 2. Teach the client that this condition is relatively minor with few symptoms. 3. Assess vital signs and observe for hypotension, tachycardia, and tachypnea. 4. Administer dexamethasone (Decadron) per the health care provider’s prescription.
    4
    1
    3
    2
    300s
  • Q9
    The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention should the nurse include in the plan of care? 1. Change the client’s positions slowly. 2. Assess the client for decreased sensation to touch. 3. Assess the client for decreased sensation to vibration. 4. Teach the client about loss of motor function and decreased pain sensation.
    4
    1
    3
    2
    300s
  • Q10
    The nurse is caring for a client with a thoracic spinal cord injury. As part of the nursing care plan, the nurse monitors for spinal shock. In the event that spinal shock occurs, which intravenous (IV) fluid should the nurse anticipate being prescribed? 1. Dextran 2. 0.9% normal saline 3. 5% dextrose in water 4. 5% dextrose in 0.9% normal saline
    1
    3
    4
    2
    300s
  • Q11
    The nurse is caring for a client with a spinal cord injury who is in spinal shock. The nurse performs an assessment on the client, knowing that which assessment will provide the best information about recovery from spinal shock? 1. Reflexes 2. Pulse rate 3. Temperature 4. Blood pressure
    4
    3
    2
    1
    300s
  • Q12
    A client with a spinal cord injury is at risk of developing footdrop. What should the nurse use as the effective preventive measure? 1. Foot board 2. Heel protectors 3. Posterior splints 4. Pneumatic boots
    3
    3
    2
    1
    300s
  • Q13
    A client is being brought into the emergency department after suffering a head injury. Which should the nurse assess first? 1. Level of consciousness 2. Pulse and blood pressure 3. Respiratory rate and depth 4. Ability to move extremities
    1
    2
    3
    4
    300s
  • Q14
    After a cervical spine fracture, this device (refer to figure) is placed on the client. The nurse develops a discharge plan for the client to ensure safety and includes which measures? Select all that apply. 1. Teach the client how to ambulate with a walker. 2. Instruct the client to bend at the waist to pick up needed items. 3. Demonstrate the procedure for scanning the environment for vision. 4. Inform the client about the importance of wearing rubber-soled shoes. 5. Teach the spouse to use the metal frame to assist the client to turn in bed.
    Question Image
    1,3,5
    1,2,4
    1,3,4
    2,3,4
    300s
  • Q15
    The nurse is caring for a client with a C-6 spinal cord injury during the spinal shock phase. What should the nurse implement when preparing the client to sit in a chair? 1. Apply knee splints to stabilize the joints during transfer 2. Teach the client to lock the knees during the pivoting stage of the transfer 3. Administer a vasodilator in order to improve circulation of the lower limbs 4. Raise the head of the bed slowly to decrease orthostatic hypotensive episodes
    3
    1
    2
    4
    300s

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