MDC 4 Exam 1 1. A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered "a test on my heart," how should the nurse respond? a. "Most of these types of blood clots come from the heart." b. "Some of the blood clots may have gone to your heart too." c. "We need to see if your heart is strong enough for therapy." d. "Your heart may have been damaged in the stroke too." - a. "Most of these types of blood clots come from the heart." An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate. 2. A nurse is assessing an adult patient in an inpatient unit. The patient states, "I came into the emergency department because I was experiencing numbness in my feet. On the way to the hospital, it got worse and went up my legs and I couldn't move them." What disease of the peripheral nervous system is the patient experiencing? - Guillain-Barré syndrome 3. Which of the following techniques are necessary for safely feeding a hemiplegic patient? (Select all that apply.) a. Mixing liquids and solid foods together b. Taking the patients dentures out to prevent choking c. Checking the affected side of mouth for food accumulation d. Offering small bites of food e. Elevating the patient to no more than 30 degrees f. Adding a thickening agent to liquids - c. Checking the affected side of mouth for food accumulation d. Offering small bites of food f. Adding a thickening agent to liquids 4. Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.) a. Yogurt b. Caffeine c. Beef d. Pears e. Marinated foods f. Milk - a. Yogurt b. Caffeine e. Marinated foods 5. What is the first sign of Bell’s palsy? a. Inability to wrinkle forehead and pucker lips on affected side b. Sudden pain in nostril on affected side c. Excessive salivation on the affected side d. Excessive mucus running from nostril on affected side - a. Inability to wrinkle forehead and pucker lips on affected side 6. A patient has recently suffered a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely? a. Use a straw b. Tuck chin when swallowing c. Take a sip of liquid with each bite d. Turn head to the left - b. Tuck chin when swallowing 7. A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (SATA) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access. - a. Have suction equipment at the bedside. d. Keep bed rails up at all times. f. Ensure that the client has IV access. 8. A client with Alzheimer's disease is admitted to the hospital. Which psychosocial assessment is most important for the nurse to complete? a. Ability to recall past events b. Ability to perform self-care c. Reaction to a change of environment d. Relationship with close family members - c. Reaction to a change of environment 9. Which responses indicate to the nurse that the patient understands preoperative teaching? (Select all that apply.) a. "I will need to sign a consent form before I am given my medications prior to my surgery." b. "The surgeon will want me to ambulate as soon as possible after my surgery." c. "My nurse will want me to take the deepest breaths I can tolerate following my surgery." d. "I may experience some constipation if I am taking much pain medication after my surgery." - "I will need to sign a consent form before I am given my medications prior to my surgery." "The surgeon will want me to ambulate as soon as possible after my surgery." "My nurse will want me to take the deepest breaths I can tolerate following my surgery." "I may experience some constipation if I am taking much pain medication after my surgery." 10. The nurse explains that the person responsible for verifying that the consent form is signed and that the surgical site is marked is the: a. scrub nurse. b. surgeon. c. anesthesiologist. d. circulating nurse. - d. circulating nurse