NURS 220 exam #3. All Questions & Answers. 100% Accurate. RATED A+
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
1. Prepare to administer recombinant tissue plasminogen act...
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left
arm and slurred speech. Which nursing intervention is priority?
1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
2. Discuss the precipitating factors that caused the symptoms.
3. Schedule for a STAT computed tomography (CT) scan of the head.
4. Notify the speech pathologist for an emergency consult. - ✔✔-3
The nurse is assessing a client experiencing motor loss as a result of a left-sided cere- brovascular
accident (CVA). Which clinical manifestations would the nurse document?
1. Hemiparesis of the client's left arm and apraxia.
2. Paralysis of the right side of the body and ataxia.
3. Homonymous hemianopsia and diplopia.
4. Impulsive behavior and hostility toward family. - ✔✔-2
Which client would the nurse identify as being most at risk for experiencing a CVA?
1. A 55-year-old African American male.
2. An 84-year-old Japanese female.
3. A 67-year-old Caucasian male.
4. A 39-year-old pregnant female. - ✔✔-1
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit.
Which interventions should be included in the nursing care plan? Select all that apply.
,1. Position the client to prevent shoulder adduction.
2. Turn and reposition the client every shift.
3. Encourage the client to move the affected side.
4. Perform quadriceps exercises three (3) times a day.
5. Instruct the client to hold the fingers in a fist. - ✔✔-1, 3
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovas- cular accident.
Which collaborative intervention will be included in the plan of care?
1. Observe the client swallowing for possible aspiration.
2. Position the client in a semi-Fowler's position when sleeping.
3. Place a suction setup at the client's bedside during meals.
4. Refer the client to an occupational therapist for evaluation. - ✔✔-4
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis.
Which action by the UAP requires the nurse to intervene?
1. The assistant places a gait belt around the client's waist prior to ambulating.
2. The assistant places the client on the back with the client's head to the side.
3. The assistant places a hand under the client's right axilla to move up in bed.
4. The assistant praises the client for attempting to perform ADLs independently. - ✔✔-3
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which
medication would the nurse anticipate being ordered for the client on discharge?
1. An oral anticoagulant medication.
2. A beta blocker medication.
3. An anti-hyperuricemic medication.
4. A thrombolytic medication. - ✔✔-1
,The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned
about her husband's generalized weakness. Which home modification should the nurse suggest to the
wife prior to discharge?
1. Obtain a rubber mat to place under the dinner plate.
2. Purchase a long-handled bath sponge for showering.
3. Purchase clothes with Velcro closure devices.
4. Obtain a raised toilet seat for the client's bathroom. - ✔✔-4
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse
include in the plan of care?
1. Potential for injury.
2. Powerlessness.
3. Disturbed thought processes.
4. Sexual dysfunction. - ✔✔-2
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic
stroke?
1. A blood glucose level of 480 mg/dL.
2. A right-sided carotid bruit.
3. A blood pressure of 220/120 mm Hg.
4. The presence of bronchogenic carcinoma. - ✔✔-3
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention
should the nurse implement first?
1. Administer a nonnarcotic analgesic.
, 2. Prepare for STAT magnetic resonance imaging (MRI).
3. Start an intravenous infusion with D5W at 100 mL/hr.
4. Complete a neurological assessment. - ✔✔-4
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a
ruptured aneurysm. Which intervention will the intensive care nurse implement?
1. Administer a stool softener b.i.d.
2. Encourage the client to cough hourly.
3. Monitor neurological status every shift.
4. Maintain the dopamine drip to keep BP at 160/90. - ✔✔-1
The client diagnosed with a mild concussion is being discharged from the emergency department. Which
discharge instruction should the nurse teach the client's significant other?
1. Awaken the client every two (2) hours.
2. Monitor for increased intracranial pressure.
3. Observe frequently for hypervigilance.
4. Offer the client food every three (3) to four (4) hours. - ✔✔-1
The resident in a long-term care facility fell during the previous shift and has a lacer- ation in the
occipital area that has been closed with Steri-Strips. Which signs/ symptoms would warrant transferring
the resident to the emergency department?
1. A 4-cm area of bright red drainage on the dressing.
2. A weak pulse, shallow respirations, and cool pale skin.
3. Pupils that are equal, react to light, and accommodate.
4. Complaints of a headache that resolves with medication. - ✔✔-2
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