NURS480 Comprehensive Practice Exam With Answers (189 Solved Questions)

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EXAM 3In planning for discharge planning for a client with bacterial meningitis, the nursewill be sure to include which instruction?1. Keep all family and visitors from visiting your room for protective isolation.2. Make sure you eat high protein diet with plenty of fluids3. Take all of the antibiotics until gone.NURS 480 EXAM 1–3 WITH SATISFIED SOLUTIONS

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4. Incorporate regular exercise with an active range of motion. - 3. Take all of theantibiotics until gone.The client should be instructed to complete all antibiotics until they are completelygone. Failure to complete antibiotics may lead to re-infection and may spreadcausing endocarditis and other infections in the body, especially if the bacteriawere from streptococci. While the client may be in isolation while in the hospital,family may not need to quarantine the client when at home. Some family membersreceive prophylactic antibiotics, but will be ordered according to the bacterialstrain and health care provider (HCP) recommendations. It is important to eat agood diet, but the most important will be taking prescribed antibiotics. Whilereturning to exercise is important, gradual increase should be performed, and theanswer selection for exercise was not as important as prescribed antibiotics.The nurse is assessing the central stimulus function of an unconscious client inthe intensive care unit. The nurse should plan to use which technique to test theclient's central response to stimuli?1. Supraorbital ridge pressure.2. Sternal rub.3. Pressure on the nail bed.4. Calling out loudly close to the client's ear. - 1. Supraorbital ridge pressure.Central stimulus is applied to cranial nerves not peripheral nerves. Supraorbitalridge pressure by applying pressure on the orbital rim is indicated for centralstimulus assessment. Sternal rub is usually not indicated via best practices.Pressure on the nail bed represents testing painful stimuli for motor testing onperipheral nerves. Calling out loudly is not an assessment technique for centralstimulus function. There are two anatomic locations for pain stimulus: centrallyand peripherally. Central involves trapezious pinch or supraorbital pressure

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whereas peripheral stimuli are applied to extremities. Responses may inferdamage to the brain or specific brain areas.A client is admitted for observation following a motor vehicle accident thatoccurred on the way to the client's daughter's wedding. The next morning, insteadof asking about the wedding, the client tells the nurse "I have to leave now sincethe wedding is in a few minutes." The client then becomes agitated when the nursere-orients and states the actual date (which is the day following the wedding).What should the nurse do next?1. Change the date on the hospital room whiteboard to yesterday's date.2. Perform neurological assessment and assess pupillary response.3. Administer Valium 40 mg IV since the client is about to have a seizure.4. Call the family to see if the wedding can be repeated - 2. Perform neurologicalassessment and assess pupillary response.The nurse needs to perform a neuro assessment to determine pupillary response,ask if a headache is present, take vital signs, and contact the health care provider.The client may be exhibiting subtle signs of increased intracranial pressure whichincludes restlessness, agitation, headache, and pupil changes.A client is taking felbamate (Felbatol) for seizures and displays symptoms ofpancytopenia based on which assessment findings? (Select all that apply)1. Sore throat2. Epistaxis3. Skin rash4. Gingival hyperplasia - 1. Sore throat2. Epistaxis

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Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-likefeeling, and may exhibit increased bleeding with reduced platelet count (epitaxis).Skin rash may not indicate pancytopenia. Gingival hyperplasia is an adverse affectof anticonvulsants like phenytoin, but is not a symptom of pancytopenia.Pancytopenia affects red cells, white cells, and platelets and represents bonemarrow's response to on-hematologic conditions such as drugs.A client is being discharged with a new prescription of phenytoin sodium (dilantin).Which instruction by the nurse is most important to include?1. If stopped abruptly, status epilepticus may occur.2. Sulfonamides like Bactrim will decrease phenytoin levels in the blood.3. Take the medication with antacids to reduce gastric upset.4. Dilantin will not affect contraceptive effectiveness. - 1. If stopped abruptly,status epilepticus may occur.It is important to instruct not to suddenly stop taking phenytoin sodium (Dilantin)as doing so may present a risk for return of life-threatening seizure activity.Sulfonamides will increase phenytoin levels. The drug should not be taken withantacids and will lower phenytoin absorption. Clients on contraceptive hormonetherapy may need to use alternative forms of non-hormonal contraceptives whileon phenytoin sodium (Dilantin).The nurse is caring for a client who is unconscious who requires enteral feedingsthrough a nasogastric tube. Which action takes priority when managing enteralfeedings?1. Weigh the client daily at the same time.2. Make sure sterile water and sterile gavage system is changed every 24 hours.3. Keep the client in semi-fowlers position.

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4. Keep the formula warm by setting in hot water 30 minutes prior toadministration. - 3. Keep the client in semi-fowlers position.It is most important to maintain a semi-flowlers position with nasogastricfeedings to prevent aspiration. While daily weights may be important, protectingthe airway and lungs from aspiration is more important. Having sterile water andsupplies are not necessary since the management is with clean not sterileprocedure. The formula should be room temperature and should never be heatedprior to administration.The nurse will collaborate with the interdisciplinary team on communication assistwith a client with expressive aphasia. The team decided on which intervention tohelp with communication?1. Make sure all staff know to speak slowly and in short sentences.2. Make sure all staff speak loudly for the client to hear.3. Make sure all staff write on a clipboard for the client to read communication.4. Make sure all staff assist the client with use of a picture board which is clientdriven. - 4. Make sure all staff assist the client with use of a picture board whichis client driven.Expressive aphasia clients may understand what is heard or written, but they maynot be able to verbally communicate their needs. A picture or communicationboard helps the client as the client can point to or direct others towards objectson the board for wants and needs. Speaking loudly or slowly is not therapeutic forcommunication and may diminish the client's dignity. Having staff to be the onlyones to write implies one-way communication that is staff-driven and not client-need driven. The focus is client-centered care and the client should beencouraged to express needs and wants through therapeutic means.

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The nurse is caring for a client with increased intracranial pressure. Whichrespiratory pattern changes will signal increased intracranial pressure?1. Rapid, shallow respirations.2. Nasal flaring.3. Slow, irregular respirations.4. Sudden increase in respiratory secretions - 3. Slow, irregular respirations.Respiratory changes associated with increased intracranial pressure are theresult of deterioration of neural control of respirations, which is controlled by thebrain stem. Deterioration and pressure produce irregular respiratory patterns.Nasal flaring and rapid shallow respirations are a sign of respiratory distresswhich may not have root causes because of neurological changes.The emergency department nurse receives a client with an ischemic stroke, andprepares to administer tissue plasminogen activator (t-PA). What question shouldthe nurse ask first before administering the t-PA?1. Ask the client which arm or leg is affected.2. Ask the client if speech was slurred.3. The nurse will ask time of onset of stroke.4. Ask what home medications the client takes. - 3. The nurse will ask time ofonset of stroke.Timing of onset of stroke is important when receiving t-PA. Studies indicate thatclients should receive the thrombolytic medication within 3 - 4.5 hours after theonset of a stroke for best outcomes. While asking about speech changes isimportant, it is more important to establish time frame of stroke onset. Otherquestions are not important as the emergent need is to determine if the client is acandidate for t-PA administration.

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A client with trigeminal neuroalgia returns to the clinic for follow-up. Whichassessment is most important for the nurse to perform for the client withtrigeminal neuroalgia?1. Skin temperature2. Determining areas of pain through palpation3. Examination of dentition4. Perform cranial nerve IX and X assessment - 3. Examination of dentitionAssessment of teeth and gums are important because dental care is often notperformed for fear of pain associated with the oral care. Skin temperature anddetermining pain on palpation are not useful, and palpation for pain may triggermore intense pain and should be avoided. Cranial nerve IX and X are not affectedby trigeminal neuralgia (trigeminal nerve is V). Trigeminal nerves controlsensations in the face. Most pain is experienced in the upper or lower jaw andruns in cyclesA nurse caring for a client with Guillain-Barré syndrome notifies the health careprovider of deteriorating condition. Which of the following assessment findingsindicate a worsening of Guillain-Barré syndrome?1. Weakness2. Paresthesia3. Thick green respiratory sputum4. Lower extremity pain - 3. Thick green respiratory sputumGuillain-Barré is characterized by paralysis which ascends through the bodyaffecting the peripheral nervous system. Serious complications may occur as aresult of respiratory infection since respiratory center is affected and failure may

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ensue. Weakness, paresthesia, and lower extremity pain may be early signs;however, they do not indicate worsening.A client with a diagnosis of muscular sclerosis (MS) is prescribed baclofen(Lioresal). During instruction to the client, the nurse explains which of thefollowing describes the preferred outcome of the drug?1. It will reduce the chance of getting viral infections.2. It will help relieve muscular spasticity.3. It will decrease depression.4. It will help with insomnia. - 2. It will help relieve muscular spasticity.Baclofen is a centrally acting muscle relaxant with a main outcome of relievingmuscle spasms that frequently occur with MS. Baclofen does not reduce chancesof getting infections, it does not decrease depression, and sedation is an adverseeffect.The nurse is caring for an 8 year-old client who is diagnosed with epilepsyfollowing an abnormal electroencephalogram (EEG). The parents are voicingdisbelief in the diagnosis and indicate they never witnessed a seizure. Which of thefollowing type of seizure will the nurse provide instruction for the parents?1. Jacksonian seizure2. Petit mal seizure3. Grand mal seizure4. Myoclonic seizure - 2. Petit mal seizurePetit mall seizures are also called absent seizures since they may be observedonly as a brief staring occurrence. They may last only 10 seconds or less;however, they are likely to develop into tonic-clonic later, so medical management

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is necessary. They usually are found between 3 and 15 years of age. Jacksonianseizure involves focal abnormal movements that usually begin in distal musclesand progress to other adjacent muscles (Motor Seizure). They last around 20-30seconds and would be noticeable by the parents. Grand mal seizures arenoticeable and the body may stiffen, jerk, shake, and loss of consciousnessoccurs. Myoclonic seizures occur with sudden muscle jerking as if shocked byelectrical current, so the parents would have observed this type.The nurse is preparing an instructional discharge plan for a client with damage tocranial nerve II. Which item will be included in the discharge instruction?1. Make sure the environment is clutter free and clear of obstacles.2. Make sure all family and caretakers speak loudly.3. Have the client to open the mouth for inspection of the tongue daily.4. Have the client to drink only thickened liquids. - 1. Make sure the environment isclutter free and clear of obstacles.Cranial nerve II is the optic nerve and visual center, so the nurse needs to ensurethat instruction on safe environment is provided. Speaking loudly may beinstruction for hearing (Cranial nerve VII). Cranial nerve X, XI, & XII are moreappropriate for answers C and D.The nurse is caring for an unconscious client and performs passive range ofmotion to which main reason?1. To ensure that joints remain mobile.2. To ensure that muscle tone is increased.3. To prevent demineralization of bone.4. To maintain muscle mass. - 1. To ensure that joints remain mobile.

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Passive range of motion maintains joint mobility and reduces the chances offreezing joints. Muscle strength relies on maintaining muscle strength and tone.Weight bearing exercises provide for bone strengthening.A client injured in a motor vehicle accident is transferred to the intensive careunit with a diagnosis of head trauma. The emergency room nurse reports theclient has increased intracranial pressure. Which assessment findings are themost important for the nurse to monitor? (Select all that apply)1. Urine output2. Rate of respirations3. Cerebral perfusion pressure4. Systolic blood pressure - 3. Cerebral perfusion pressure4. Systolic blood pressureThe systolic plus diastolic blood pressures are important and necessary in orderto monitor mean arterial pressure (MAP). The MAP is necessary to assess since itreflects pressure required for brain perfusion with each cardiac cycle.Theintracranial pressure (ICP) and MAP will provide analysis of cerebral perfusionpressure. While urine output, respiratory rate are important, the question isfocused on critical indicators associated with head trauma.The nurse is instructing a client on the causes of Bell's palsy. What is the nurse'sbest explanation for Bell's Palsy?1. It may be triggered following exposure to herbicide or poison.2. It's cause may be unknown.3. It may be triggered from malnutrition4. It may be triggered from drug and alcohol addiction - 2. It's cause may beunknown.

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The exact cause of Bell's Palsy is unknown, but some studies suggest it mayinclude viral exposures like herpes, autoimmune diseases, or other conditions.There is no solid evidence to suggest it has a correlation with herbicides, toxins,or drug or alcohol addictions. There is no evidence linking Bell's Palsy withmalnutrition.The evening nursing is caring for a client with new onset of myasthenia gravis. Thenurse expects to find which of the following assessment observations?1. Hand tremors when lifting a gallon of milk.2. Stronger hand grips and steadier gait3. Pain and tingling to extremities4. Blurred vision and unclear speech patterns - 4. Blurred vision and unclearspeech patternsMyasthenia gravis is a chronic autoimmune neuromuscular disease that causesweakness in skeletal muscles including those that control breathing and eyemovement. Antibodies block, alter, or destroy receptors for acetylcholine at theneuromuscular junction which prevents muscular contraction. Vision changes,difficulty swallowing, breathing, ptosis, speech, and peripheral weakness aresymptoms, and may worsen as the day progresses, so symptoms may be worse inlater times of the day. While tremors when lifting the weight of a gallon of liquidmay not be a cardinal sign, even though tremors may occur with profoundweakness that may occur while using muscles for small low weight tasks. Visionand speech impairments are some of the first noticeable symptoms.The nurse is caring for a client with spinal cord injury and is preparinginstructional plan for the client and family on autonomic dysreflexia. Which

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teaching promotes the best measure to minimize occurrence of autonomicdysreflexia?1. Perform bladder catheterization to once each 12 hours.2. Use nitroglycerin ointment for low blood pressure.3. Perform range of motion at least 4 times per day.4. Perform bladder catheterization at least every 4 hours. - 4. Perform bladdercatheterization at least every 4 hours.The nurse should instruct the client and family to make sure the bladder is not fullsince a full bladder may trigger an autonomic dysreflexia response, which maylead to increased blood pressure and possible stroke. Nitroglycerin may be usedat the onset of autonomic dysreflexia for increased blood pressure. Some signsare headache, flushed skin, or sweating above the spinal cord injury occurs. Thenitro past helps to bring blood pressure down quickly. Performing range of motiondoes not lessen chances of autonomic reflexia.Which cranial motor nerve controls the movement of the trapezius andsternocleidomastoid muscles of the shoulder?1. Abducens2. Trigeminal3. Spinal accessory4. Glossopharyngeal - 3. Spinal accessoryA client with a diagnosis of epileptic seizures is on anticonvulsant therapy,phenytoin and is at the clinic for follow-up. The client reveals signs of centralnervous system (CNS) depression with complaints of increased lethargy andconfusion. The nurse provides further instruction on CNS depression after theclient discloses use of which of the following?

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1. Alcohol2. Furosemide3. Metformin4. Calcium - 1. AlcoholUse of alcohol with phenytoin can increase CNS depression. The nurse shouldprovide further education if a client discloses the use of alcohol while takingphenytoin.The nurse is assessing a client who has been on phenytoin for 10 years. Whichcharacteristic finding is observed in clients with a long-term history of takingphenytoin sodium?1. Excessive growth of gum tissue.2. Enlarged tonsils.3. Dry scaly skin.4. Mania - 1. Excessive growth of gum tissue.Phenytoin is used to prevent and treat seizures. Long-term use of phenytoin cancause gingival hyperplasia (excessive growth of gum tissue).The nurse is caring for a client who was admitted 8 hours ago for a traumaticbrain injury. The client's Glasgow Coma Scale score was 15 upon arrival, but nowthe client's GCS score is 6. What is the priority intervention?1. Reposition the client and lower the head of the bed.2. Call the Medical Response Team to code the client.3. Increase the client's oxygen to 4 Liters/minute.

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4. Notify the healthcare provider immediately. - 4. Notify the healthcare providerimmediately.The total Glasgow coma scale (GCS) highest score is 15, which is considerednormal brain activity. If the client's GCS is less than 8, the client is consideredneurologically unstable, a medical emergency, and will be placed in the intensivecare unit.A client with Guillain-Barre syndrome will be receiving immunoglobulin therapy(IVIG) and questions the nurse about the purpose of the treatment. Whichstatement by the nurse is correct?1. "The liquid portion of part of your blood called plasma, is removed and replacedwith healthy plasma to remove the antibodies that are harming your immunesystem."2. "Donated blood plasma that contains certain antibodies is given to provide yourbody with the antibodies needed to fight infection."3. "Intravenous corticosteroid treatment is administered to reduce nerveinflammation associated with Guillain-Barre syndrome."4. "Intravenous injection of synthetically made proteins that perform like humanantibodies to fight off harmful antigens." - 2. "Donated blood plasma that containscertain antibodies is given to provide your body with the antibodies needed to fightinfection."Immunoglobulin therapy is blood plasma donated by healthy donors givenintravenously to provide the body with the antibodies needed to fight infection.High doses of immunoglobulin can impede the injurious antibodies that presentwith GBS.

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The nurse is caring for a client with a Glasgow coma scale of 5. What finding wouldthe nurse expect with a coma scale of 5?1. The client is alert & oriented X 42. The client is alert but confused3. The client is severely confused4. The client is in a coma - 4. The client is in a comaThe total Glasgow coma scale (GCS) highest score is 15, which is considerednormal brain activity. If the client's GCS is less than 8, the client is consideredneurologically unstable, a medical emergency, and will be placed in the intensivecare unit. The GCS assesses best eye opening response, best verbal response, andbest motor response. When a client's GCS is 13-15, the client has mild brain injury;a GCS of 9-12 indicates moderate brain injury; and a GCS of 3-8 is severe braininjury. If the client has a GCS of 5, the client would be found comatose.The nurse caring for a client with a brain injury administered mannitol forincreased intracranial pressure. Which is the most important for the nurse tomonitor following administration of mannitol?1. Intake and output.2. Pupillary response.3. Changes in pulse pressure4. Respiratory rate. - 1. Intake and output.Which nursing diagnosis is appropriate for the client with Guillain-Barresyndrome?1. Impaired skin integrity2. Risk for ineffective breathing pattern

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