Nursing 138 Exam 1 Practice Questions and Correct Answers
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Course
NUR 138
Institution
NUR 138
A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure? 1) Maintaining the client in the supine position for several hours 2) Encouraging the client to ambulate every hour for at least 6 hours 3) Keeping the client in the Trendelenburg position for ...
Nursing 138 Exam 1 Practice Questions
and Correct Answers
A client is scheduled for a lumbar puncture. What nursing care should be implemented
after the procedure? ✅1) Maintaining the client in the supine position for several hours
2) Encouraging the client to ambulate every hour for at least 6 hours
3) Keeping the client in the Trendelenburg position for at least 2 hours
4) Placing the client in the high-Fowler position immediately after the procedure
Correct Answer: 1
Rational: Staying flat may help to prevent spinal fluid leakage and postprocedure
headache; this is recommended, even though some people develop a headache
despite this precaution. Encouraging the client to ambulate every hour for at least 6
hours may predispose to spinal fluid leakage; the client should be kept flat for 6 to 12
hours. The Trendelenburg position may increase intracranial pressure and is not
appropriate. Placing the client in the high-Fowler position immediately after the
procedure may predispose to spinal fluid leakage; the client should be kept flat.
During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré
syndrome, what does the nurse expect the client to manifest? ✅1) Diminished visual
acuity
2) Increased muscular weakness
3) Pronounced muscular atrophy
4) Impairment in cognitive reasoning
Correct Answer: 2
Rational: Muscular weakness with paralysis results from impaired nerve conduction
because the motor nerves become demyelinated. Diminished visual acuity usually is not
a problem; motor loss is greater than sensory loss, with paresthesia of the extremities
being the most frequent sensory loss. Demyelination occurs rapidly early in the disease,
and the muscles will not have had time to atrophy; this can occur later if rehabilitation is
delayed. Only the peripheral nerves are involved; the central nervous system is
unaffected.
A client has undergone nasal hypophysectomy surgery. During post-operative care,
which finding indicates cerebrospinal leakage? ✅1) Dry mouth
2) Rigidity of neck muscles
3) Fall in blood pressure upon standing
4) A yellow edge around nasal discharge
Correct Answer: 4
Rational: Nasal hypophysectomy is a surgical procedure performed to treat
hyperpituitarism due to pituitary gland tumors. During postoperative care and follow-up,
, the appearance of light-yellow at the edge of otherwise clear nasal discharge in the
dressing indicates leakage of cerebrospinal fluid (CSF). This is called the "halo sign"
and is indicative of a CSF leak. Dry mouth after nasal hypophysectomy is normal
because the client breathes through the mouth due to the nasal packing. Neck rigidity
could be an indication of infection, such as meningitis following the surgery. A fall in
blood pressure upon standing is called orthostatic hypotension and is a side effect of
bromocriptine.
What is a clinical manifestation of a cluster headache? ✅1) Vertigo
2) Neck rigidity
3) Phonophobia
4) Ipsilateral tearing of the eye
Correct Answer: 4
Rational: Ipsilateral tearing of the eye, or tearing on the same side as the headache, is a
clinical manifestation of cluster headaches. Neck rigidity, vertigo, and phonophobia are
manifestations of migraine headaches.
A nurse is caring for a client with Addison's disease. Upon assessment, which classic
sign will the nurse find? ✅1) Ecchymosis
2) Hyperreflexia
3) Exophthalmos
4) Hyperpigmentation
Correct Answer: 4
Rational: Hyperpigmentation, or "bronzing," is a classic sign of Addison's disease.
Ecchymosis (bruise) is the discoloration of the skin due to rupture of blood vessels
beneath the skin. Hyperreflexia is a sign of hypoparathyroidism. Exophthalmos is the
classic sign of hyperthyroidism.
After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome
of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are
exhibited with excessive levels of antidiuretic hormone? ✅1) Increased blood urea
nitrogen (BUN) and hypotension
2) Hyperkalemia and poor skin turgor
3) Hyponatremia and decreased urine output
4) Polyuria and increased specific gravity of urine
Correct Answer: 3
Rational: Antidiuretic hormone (ADH) causes water retention, resulting in a decreased
urine output and dilution of serum electrolytes. Blood volume may increase, causing
hypertension. Diluting the nitrogenous wastes in the blood decreases rather than
increases the BUN. Water retention dilutes electrolytes. The client is overhydrated
rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause
water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume.
The specific gravity of urine is elevated as a result of increased concentration.
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