MS3 Exam 1 Lewis Flashcards

A patient is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?

The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?

A nurse reviews the laboratory data for an older adult. The nurse would be most concerned about which finding?

A patient with pancytopenia will have a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?

The nurse assesses a patient with pernicious anemia. Which finding would the nurse expect?

A patient’s complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?

The nurse is reviewing laboratory results and notes a patient’s activated partial thromboplastin time (aPTT) level is 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?

The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered?

The nurse examines the lymph nodes of a patient during a physical assessment. Which finding would be of most concern to the nurse?

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?

The health care provider’s progress note for a patient states that the complete blood count (CBC) shows a “shift to the left.” Which assessment finding should the nurse expect?

The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take to prepare the patient for this procedure?

A patient with pancytopenia of unknown origin is scheduled for diagnostic tests. The nurse will ensure a consent form was signed before which test?

The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider?

16. Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider?

Assessment

BP 110/68
• Pulse 98 beats/min
• Brisk capillary refill
• Multiple ecchymoses on arms

Complete Blood Count

Hgb 10.6 g/dL
• Hct 30%
• WBC 5100/μL
• Platelets 19,500/μL

Patient History

Occasional aspirin use
• Abdominal pain x 1 week • Large, dark stool this morning

An adult male with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms?

Which menu choice indicates that the patient understands the nurse’s recommendations about dietary choices for iron-deficiency anemia?

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. Which nutrient supplement should the nurse plan to explain to the patient?

Which patient statement to the nurse indicates that the patient understands self-care for pernicious anemia?

Which is an appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia?

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?

Which potential complication should the nurse identify as a high risk for a patient admitted to the hospital with idiopathic aplastic anemia?

Which nursing intervention is important when providing care for a patient with sickle cell crisis?

Which statement by a patient indicates good understanding of the nurse’s teaching about preventing sickle cell crisis

Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis

The nurse observes scleral jaundice in a patient being admitted with hemolytic anemia. Which laboratory result the nurse should check?

A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/μL. Which action will the nurse include in the plan of care?

What action is expected by the nurse caring for a patient who has an acute exacerbation of polycythemia vera?

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura?

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)?

The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. Which action should the nurse take?

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. Which laboratory value should the nurse monitor?

A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. What should the nurse plan to explain to the patient?

Which action will the admitting nurse include in the care plan for a patient who has neutropenia?

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?

A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?

A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient?

A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). What is the best approach for the nurse to assist the patient with this treatment decision

Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma?

Which nursing intervention is appropriate for a patient with non-Hodgkin’s lymphoma whose platelet count drops to 18,000/μL during chemotherapy?

A patient receiving outpatient chemotherapy for myelogenous leukemia develops an absolute neutrophil count of 850/μL. Which collaborative action should the outpatient clinic nurse anticipate?

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider?

The nurse is planning to administer a transfusion of packed blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

A patient in the emergency department reports back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. What should the nurse’s first action be?

Which patient should the nurse assign as the roomate for a patient who has aplastic anemia?

Which patient requires the most rapid assessment and care by the emergency department nurse?

A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets?

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provide

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first?

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/VN)?

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?

After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first?

Which action will the nurse include in the plan of care for a patient who has thalassemia major

Which information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?

Following successful treatment of Hodgkin’s lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching?

A patient who has non-Hodgkin’s lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provide

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?

The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider?

History

Fatigue, which has increased over last month • Frequent constipation

Physical Assessment

Conjunctiva pale pink, moist
• Multiple bruises
• Clear lung sounds

Laboratory Results

Hct 33%
• WBC 1500/μL
• Platelets 70,000/μL

When admitting an acutely confused patient with a head injury, which action should the nurse take?

Which finding should the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?

What should the nurse include in a focused assessment of a patient’s left posterior temporal lobe functions?

How should the nurse assess the patient’s trigeminal and facial nerve function (CNs V and VII)

Which action should the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?

An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider should the nurse question?

A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse’s directions to move his hands and feet. What should the nurse suspect as a likely cause of these findings?

A patient has a tumor in the cerebellum. What goal should the nurse use to focus the plan of care?

Which problem should the nurse expect for a patient who has a positive Romberg test result?

Which test should the nurse anticipate discussing with a patient who has a possible seizure disorder?

Which equipment should the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction?

Which information about a 76-yr-old patient should the nurse identify as uncharacteristic of normal aging?

The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further teaching about neurologic assessment?

1Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider?

A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans?

Which of the following should the nurse consider the priority nursing assessment for a patient being admitted with a brainstem infarction?

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient should the nurse assess first?

Which assessments should the nurse make to monitor a patient’s cerebellar function? (Select all that apply.)

Which nursing actions should be included in the plan of care for a patient after cerebral angiography? (Select all that apply.)

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation?

Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mmHg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication’s effectiveness?

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How should the nurse record the patient’s Glasgow Coma Scale score?

An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient’s spouse and teenage children stay at the patient’s side and ask many questions about the treatment. What action is best for the nurse to take?

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take?

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient’s nose. Which admission order should

the nurse question?

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome?

When assessing a patient who has a right frontal lobe tumor, what finding should the nurse expect?

1Which statement by a patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse?

After having a craniectomy and left anterior fossae incision, a 64-yr-old patient has weakness, impaired physical mobility, and a decreased level of consciousness. Which nursing action will be included in the plan of care?

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

When assessing an adult who has bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention?

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now reporting a headache. Which prescribed intervention should the nurse implement first?

After the emergency department nurse has received a status report on the following patients with head injuries, which patient should the nurse assess first?

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

After evacuation of an epidural hematoma, a patient’s intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?

A patient with increased intracranial pressure after a head injury has a ventriculostomy in place. Which action can the nurse delegate to the unlicensed assistive personnel (UAP) who regularly works in the intensive care unit?

Which information about a 30-yr-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse

The nurse is caring for a patient who has a head injury and fractured right arm. Which assessment information requires rapid action by the nurse?

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions?

While admitting a 42-yr-old patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first?

A patient with possible viral meningitis is admitted to the nursing unit after a lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question?

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for related functional deficits?

During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe?

Which is the correct point on the accompanying figure where the nurse will assess for ecchymosis when admitting a patient with a basilar skull fracture?

What topic should the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, and dysarthria with no residual effects?

patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin?

A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect?

During change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. What finding should the nurse anticipa

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel (Plavix)?

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient?

A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate?

What concern should the nurse anticipate for a patient who had a right hemisphere stroke?

Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke??

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care?

A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care?

A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take?

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program?

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, “I don’t need the aspirin today. I don’t have a fever.” Which action should the nurse take?

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the patient?

A patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond?

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address?

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient?

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?

After receiving change-of-shift report on the following four patients, which patient should the nurse see first?

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?

The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on patient information shown in the accompanying figure, which action should the nurse

A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol?(SATA)

The nurse should determine that teaching about migraine headaches has been effective when the patient says which of the following?

Which finding should the nurse expect when assessing a patient who is experiencing a cluster headache

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, “I cannot teach any more. It will be too upsetting if I have a seizure at work.” How should the nurse respond to specifically address the patient’s concern?

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse should know that this history is consistent with what type of seizure?

What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?

A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. How should the nurse respond?

A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information should the nurse include in patient teaching?

Which information about a patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)?

Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

A patient with Parkinson’s disease has bradykinesia. Which action should the nurse include in the plan of care?

What should the nurse advise a patient with myasthenia gravis (MG) to do?

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient?

A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which action should the nurse include in the plan of care?

A 40-yr-old patient is diagnosed with early Huntington’s disease (HD). What information should the nurse provide when teaching the patient, spouse, and adult children about this disorder?

A 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling–type tremor. What should the nurse anticipate explaining to the patient

A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take?

A hospitalized patient reports a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medication should the nurse administer initially?

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches that are present on wakening. Which action should the nurse plan to take first?

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

The nurse observes a patient ambulating in the hospital hall. The patient’s arms and legs suddenly jerk and the patient falls to the floor. What action should the nurse take first?

Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?

The home health registered nurse (RN) is planning care for a patient with seizure disorder related to a recent head injury. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson’s disease. Which assessment finding should indicate to the nurse that a change in the medication or dosage may be needed?

Which patient problem should the nurse identify as of highest priority for a patient who has Parkinson’s disease and is unable to move the facial muscles?

Which assessment should the nurse identify as most important regarding a patient with myasthenia gravis?

After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient reports nausea and severe abdominal cramps. Which action should the nurse take first?

A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?

Which intervention should the nurse include in the plan of care for a patient who has primary restless legs syndrome (RLS) and is having difficulty sleeping?

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

After change-of-shift report, which patient should the nurse assess first?

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient’s assigned room? (Select all that apply.)

A patient with Parkinson’s disease is admitted to the hospital for treatment of pneumonia. Which interventions should the nurse include in the plan of care? (Select all that apply.)

A patient hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia?

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who is admitted for other health problems?

What action should the nurse incorporate when administering a mental status examination to a patient with delirium?

The nurse is concerned about a postoperative patient’s risk for injury during an episode of delirium. What is the nurse’s most appropriate action?

A patient seen in the outpatient clinic is newly diagnosed with mild cognitive impairment (MCI). Which action will the nurse include in the plan of care?

The nurse is administering a mental status examination to a patient who has hypertension. The nurse suspects depression when the patient responds to the nurse’s questions with

A patient is diagnosed with moderate dementia after multiple strokes. What would the nurse expect to find during assessment of the patient?

Which action will help the nurse determine whether a new patient’s confusion is caused by dementia or delirium?

A 72-yr-old patient is brought to the clinic by the patient’s spouse, who reports that the patient is unable to solve common problems around the house. To obtain information about the patient’s current mental status, which question should the nurse ask the patient?

A patient is being evaluated for Alzheimer’s disease (AD). What should the nurse explain to the patient’s adult children?

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia?

A patient who has severe Alzheimer’s disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care?

A patient with Alzheimer’s disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take?

What should be the nurse’s initial action for a patient with moderate dementia who develops increased restlessness and agitation?

When administering the Mini-Cog exam to a patient with possible Alzheimer’s disease, which action will the nurse take?

Which hospitalized patient will the nurse assign to the room closest to the nurses’ station?

After change-of-shift report on the Alzheimer’s disease/dementia unit, which patient will the nurse assess first?

After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimer’s disease (AD), which topic will be most important for the nurse to discuss with the patient?

The spouse of a 67-yr-old male patient with early stage Alzheimer’s disease (AD) tells the nurse, “I am exhausted from worrying all the time. I don’t know what to do.” Which actions are best for the nurse to take at this time? (Select all that apply.)

Which actions could the nurse delegate to a licensed practical/vocational nurse (LPN/VN) who is part of the team caring for a patient with Alzheimer’s disease? (Select all that apply.

What information would the nurse seek from a patient with newly diagnosed trigeminal neuralgia?

Which patient assessment would help the nurse identify potential complications of trigeminal neuralgia?

What action would help the nurse evaluate outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia?

Which action would the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia?

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell’s palsy. Which information should the nurse include in teaching the patient?

A patient with Bell’s palsy refuses to eat while others are present because of embarrassment about drooling. What is the nurse’s best response?

To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse’s most immediate action?

A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate?

A construction worker arrives at an urgent care center with a deep puncture wound from a rusty nail. The patient reports having had a tetanus booster 6 years ago. What intervention should the nurse anticipate?

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which finding on the nursing assessment is congruent with neurogenic shock?

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which action should the nurse include in the plan of care?

What should the nurse explain to the patient who has a T2 spinal cord transection injury?

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?

What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr-old patient with a C6 spinal cord injury?

A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, “I want to be transferred to a hospital where the nurses know what they are doing.” Which action should the nurse appropriately take?

A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. What should the nurse identify as the most appropriate action at this phase of rehabilitation?

A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by the health care provider should the nurse question?

Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

A patient is hospitalized with new onset of Guillain-Barré syndrome. What should the nurse recognize as the most essential assessment to complete?

What action should the nurse identify as most important before administering botulinum antitoxin to a patient in the emergency department?

A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. What initial intervention should the nurse perform?

A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, “I have a pounding headache and I feel sick to my stomach.” Which action should the nurse take first?

A patient is being evaluated for a possible spinal cord tumor. Which finding should the nurse recognize as requiring the most immediate action

Which nursing action for a patient with Guillain-Barré syndrome should the nurse identify as appropriate to delegate to experienced unlicensed assistive personnel (UAP)?

Which action should the nurse take when caring for a patient who develops tetanus from injectable substance use?

Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury?

After change-of-shift report on the neurology unit, which patient should the nurse assess first?

Which assessment finding in a patient with a spinal cord tumor requires immediate action by the nurse?

A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which information should the nurse include in an initial response?

Which collaborative and nursing actions should the nurse include in the plan of care for a patient who experienced a T2 spinal cord transection 24 hours ago? (Select all that apply.)