Adult Health lll Exam 4 Answers

Starting on question #3

1. The nurse on the neurological unit is positioning a client who had a stroke two days ago

and had left-sided hemiparesis. Which of the following actions by the nurse would be

appropriate? Select all that apply.

a. Positioning a rolled washcloth in the client’s left hand

b. Placing a foam abduction wedge between the client’s legs

c. Grasping the client’s left arm to pull the client from supine to a right side-lying

position

d. Securing the left arm in a sling

e. Putting a trochanter roll on the outside of the client’s left hip when the client is

supine.

2. The nurse is caring for a client who has expressive aphasia following a stroke. The nurse

has taught the client’s spouse about ways to facilitate communication. Which of the

following comments by the client’s spouse would require follow-up?

a. “I wait after I ask my spouse a question, to give as much time as needed to

answer.”

b. “I ask my spouse questions like, ‘Do you like this movie?’ instead of ‘What do

you think of this movie?’”

c. “I act like I understand when I do not, so that my spouse will not become

frustrated.”

d. “I tell my spouse, ‘Point to what you want” so I do not get frustrated trying to

understand.”

3. The nurse is caring for a client with increased intracranial pressure (ICP) who has

developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the

following prescribed interventions should the nurse implement?

a. Electrolyte restriction

b. Electrolyte replacement

c. Fluid replacement

d. Fluid restriction

4. The nurse is planning care for a client who has a recent diagnosis of multiple sclerosis

(MS). Which of the following interventions should the nurse include in the client’s care

plan?

a. Instruct the client on daily muscle stretching exercises

b. Provide total assistance with all activities of daily living (ADLs)

c. Encourage the client to follow a low-residue diet

d. Encourage client to void every hour

5. The nurse is caring for a group of assigned clients. Which of the following client’s should

the nurse see first?

a. The client with ulcerative colitis who reports left lower quadrant abdominal pain

and passing stools that appear bloody with mucus and pus.

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b. The client with breast cancer receiving prescribed chemotherapy whose platelet

count is 52,000/uL and reports having shaking chills.

c. The client with hepatitis B virus who was admitted with jaundice and now has

changes in cognitive function.

d. The client recovering from an ischemic stroke who has decreased lung sounds,

productive cough and a temperature of 104.8 F.

6. The nurse is planning an education conference about anticoagulation and the direct factor

Xa inhibitor medications. Select all that apply.

a. Aspirin

b. Coumadin

c. Dipyridamole

d. Rivaroxaban

e. Apixaban

7. The nurse in an outpatient setting is assessing a client’s risk for ischemic stroke. The

nurse should assess for which of the following conditions? Select all that apply.

a. Atrial fibrillation

b. Hemophilia

c. Diabetes Mellitus

d. Epilepsy

e. Concussion

f. Carotid Stenosis

8. The nurse is caring for a client with a traumatic brain injury (TBI) following a fall. Which

of the following medications should the nurse anticipate being prescribed for the client to

reduce cerebral edema?

a. Mannitol

b. Spirolactone

c. Furosemide

d. Hydrochlorothiazide

9. The nurse is preparing to administer prescribed dexamethasone 7.5 mg daily in divided

doses every 6 hours to a client with vasogenic edema. The nurse has 10 mg/mL available.

How many mL per dose should the nurse administer? Round your answer to the nearest

tenth place. 0.2

10. The nurse is preparing to prescribe bevacizumab 10 mg/kg, IV, every 14 days for a client

with a glioblastoma. The client weighs 160 lbs. The nurse has available 25 mg/mL. How

many mL per dose should the nurse administer to the client? 29

11. The nurse is admitting a 16-year-old client who returned home early from summer camp

with fever, severe headache, and vomiting. Which of the following prescribed

interventions should the nurse implement first?

a. Prepare the client for lumbar puncture

b. Administer antibiotics and pain medication

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