Download NUR 242 EXAM 4|2025|2026|QUESTIONS AND ANSWERS|173 TERMS|A+ and more Exams Nursing in PDF only on Docsity!
NUR 242 EXAM 4|2025|2026|QUESTIONS AND
ANSWERS|173 TERMS|A+
The nurse is planning care for an immobilized client who had a stroke with right-sided hemiparesis. Which activity would the nurse include in the plan of care? Assist the client to perform range-of-motion (ROM) exercises every 1 to 2 hours Which is the priority nursing action for a client admitted to the hospital in a coma after having a stroke? Maintain an open airway. Which position would the nurse plan to use for the client who is having a hypertensive crisis and evolving stroke? Side-lying
Which nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? Place objects within the visual field Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is rising. Which complication would the nurse plan to address? Increased intracranial pressure The registered nurse (RN) is caring for a client who is currently hospitalized for a stroke. Which professional management strategy will be most effective for the RN to improve the safety and quality of client care? Delegation The client taking intravenous coagulant medications for a bleeding disorder suddenly develops an embolic stroke as a result of medication overdose. Which actions by the hospital management does the
A client has had a recent brain attack (cerebrovascular accident/stroke). Which preventative would the nurse anticipate will be prescribed daily to avoid straining due to constipation? Stool softener Which intervention would the disaster management team nurse perform for the survivors of an explosion who developed heat stroke? Apply ice packs on the client's scalp Which level of care is the nurse providing when preparing to discharge a client who is learning to walk again after a stroke to a rehabilitation center? tertiary care Which action by the emergency department nurse is the priority for a client with heat stroke?
Assess the airway and breathing A client who sustains a stroke has a loss of proprioception and fine touch. Which artery would the nurse suspect is damaged? Anterior cerebral A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which areas of paralysis would the nurse expect to find upon assessment? Select all that apply. One, some, or all responses may be correct. Left leg Left arm Left side of face Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later, the nurse identifies that one pupil reacts more slowly than the other and the client's systolic blood pressure is increasing. For which condition would the nurse prepare to intervene?
Which reflex is the nurse testing when using a dull object to stroke from the lateral sole of a client's foot upward to the great toe? Babinski A client admitted to the hospital with the diagnosis of a right-sided "brain attack" (stroke) is right-handed. Which task will be most difficult for this client? Dressing every morning The nurse assessed a client who experienced a recent brain attack (stroke) and has a residual right-sided hemiplegia. Which rationale explains the importance of the nurse identifying mobility restrictions or neuromuscular abnormalities when assessing this client? Shortening and eventual atrophy of the affected muscles will occur Which condition of a client with hemorrhagic stroke resulting from a motor bike accident requires immediate attention? Body temperature of 81.2°F
In which order would the nurse caring for a client suffering from heatstroke provide emergency interventions? Ensure a patent airway. Remove the client from the hot environment. Remove the client's clothing Pour or spray cold water on the client's body and scalp. Fan the client with newspapers or whatever is available. Place ice in cloth or bags and position the packs on the client's scalp Emergency care should be provided to the client with heatstroke to restore thermoregulation. First the nurse would ensure a patent airway. Then the nurse would remove the client from the hot environment into air conditioning or shade and remove his or her clothing. Then the nurse would pour or spray cold water on the client's body and scalp. The client should be fanned with newspapers or whatever is available. This should be followed by placing ice in cloth or bags and positioning the packs on the client's scalp. Which priority interventions would the nurse provide to the client hospitalized with heatstroke, a body temperature of 106°F, and skin that is hot and dry? Select all that apply. One, some, or all responses may be correct
The body temperature of a client with heatstroke is above 104°F (40°C). Which is the priority order the nurse would use for cooling the client so that breathing and circulation are not impaired? The nurse will take off the client's clothing. The nurse would place ice packs on the neck, axillae, chest, and groin. The nurse would immerse the victim in cold water. The nurse would fan the client rapidly to aid in cooling by evaporation. Which prehospital care intervention is the priority for the client with heatstroke? Withholding food or liquid to the victim The client with which National Institutes of Health Stroke Scale (NIHSS) score would be treated first? 3 for facial palsy 109 F 42.8 C (109-32):5/
A client reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as a heat stroke? increased heart rate An older adult client is admitted to the health care facility following a stroke. Which action is correct when the client's cousin asks to see the client's health record? Explain that medical health records are confidential The nurse was assessing an older adult client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. Which would be the approximate stroke volume? 70 ml The nurse is preparing to discharge a client who is partially paralyzed after a stroke. Which behaviors would the nurse alert the family of as symptoms of caregiver role strain? Select all that apply. One, some, or all responses may be correct. Disturbed sleep patterns Reduced appetite and weight
Which information would the nurse include when explaining the cause of transient ischemic attacks (TIAs) to a client? Atherosclerotic plaques within arteries Which explanation would the nurse provide to a client about transient ischemic attacks (TIAs)? Temporary episodes of neurological dysfunction A client diagnosed with a transient ischemic attack (TIA) related to hypertension is discharged with a prescription of hydrochlorothiazide. Which instruction would the nurse include when teaching about this medication? Increase the intake of potassium-rich foods." After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide. Which instruction will the nurse give the client regarding nutrition? Eat more dark green, leafy vegetables such as spinach.
Which device would the nurse use to prevent footdrop for a client on bed rest after a cerebrovascular accident? Splints The spouse of a client who had a cerebrovascular accident asks the home health nurse why the client cries easily and without provocation. Which response would the nurse provide? This behavior is a common response over which the client has little control Which goal is a priority for a client who is unconscious after a cerebrovascular accident? Maintaining the airway Which is the priority nursing intervention for a client admitted to the hospital with a brain attack (cerebrovascular accident)? Monitoring for increased intracranial pressure
The spouse of a client who had a cerebrovascular accident seems unable to accept the goal that the client will participate in self-care. Which response would the nurse make? Ask the spouse for assistance in planning activities most helpful to the client Three days after admission to the hospital for a brain attack (cerebrovascular accident [CVA]), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action would the nurse take to evaluate whether the feeding is being absorbed? Aspirate for a residual volume A client who recently experienced a brain attack (cerebrovascular accident [CVA]) and has limited mobility reports constipation. Which is most important for the nurse to determine when collecting information about the constipation? Length of time this problem has existed
A client who had a cerebrovascular accident reports feeling lightheaded and dizzy when moving from a lying to a standing position. Which information would the nurse include when explaining the cause of these symptoms? Blood pooling in the lower extremities A client who had a cerebrovascular accident leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. Which nursing action would the client's plan of care include? Teaching the client to use head movement to scan the left field of vision A client's cerebrovascular accident results in right hemiplegia. Which exercises would the nurse incorporate into the plan of care while the client is on bed rest? Passive range-of-motion exercises A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client's rehabilitation?
After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. Which specific range-of-motion exercise would the nurse teach the client? Opposition When assessing a client with a diagnosed "brain attack" (cerebrovascular accident [CVA]), the nurse evaluated the baseline vital signs of pulse rate of 78 beats per minute (bpm) and a blood pressure (BP) of 120/80 mm Hg. Which changes in the baseline vital signs indicate an increasing intracranial pressure (ICP)? Pulse 50 bpm and BP 140/60 mm Hg A client who sustained a cerebrovascular accident (CVA, also known as a "brain attack") becomes incontinent of feces. Which nursing intervention is most important for supporting the success of the client's bowel training program? Adhere to a definite time for attempted evacuations The nurse assists a client on a rehabilitation unit after a cerebrovascular accident (CVA, also known as a "brain attack") with residual hemiparesis to walk with the use of a cane. To help achieve the
goal of safe walking with a cane, which method would the nurse teach the client? Advance the cane and the affected extremity simultaneously. A client who had a cerebrovascular accident (CVA, also known as a "brain attack") begins to eat lunch. Which client behavior indicates the client may be experiencing left hemianopsia? The client ignores the food on the left side of the tray when eating Which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident (CVA, also known as a "brain attack")? Transient ischemic attacks (TIAs) Which action would the nurse implement to assist a client's development of independence, after experiencing a cerebrovascular accident (CVA) 2 weeks ago? Reinforce success in tasks accomplished
