Remerciez-le!

Remerciez @Admin pour avoir partagé cet document gratuitement, de la manière la plus simple, en partageant sur les réseaux sociaux.

1. Regular oral hygiene is an essential intervention for the client who has had

1. Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client’s mouth with a padded tongue blade. 4. Cleaning the client’s mouth and teeth with a toothbrush. 2. A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for A STAT computer tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult. 3. A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? 1. Current medications. 2. Complete physical and history. 3. Time of onset of current stroke. 4. Upcoming surgical procedures. 4. During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s: 1. Pulse 2. Respirations 3. Blood pressure 4. Temperature 5. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Cholesterol level 2. Pupil size and pupillary response 3. Bowel sounds 4. Echocardiogram 6. What is the expected outcome of thrombolytic drug therapy? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage 7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta-blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication. 8. Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female. 9. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dl. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mmHg. 4. The presence of bronchogenic carcinoma. 10. The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client’s waist prior to ambulating. 2. The assistant places the client on the back with the client’s head to the side. 3. The assistant places her hand under the client’s right axilla to help him/her move up in bed. 4. The assistant praises the client for attempting to perform ADL’s independently. Answers and Rationale 1. Answer: 1. Placing the client on the back with a small pillow under the head. A helpless client should be positioned on the side, not on the back. This lateral positionhelps secretions escape from the throat and mouth, minimizing the risk of aspiration.  Option B: It may be necessary to suction, so having suction equipment at the bedside is necessary.  Option C: Padded tongue blades are safe to use.  Option D: A toothbrush is appropriate to use. 2. Answer: 3. Schedule for A STAT computer tomography (CT) scan of the head. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use rt-PA. This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated.  Option A: rt-PA is contraindicated.  Options B and D: Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching. Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol. 3. Answer: 3. Time of onset of current stroke. The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes.  Option A: Current medications are relevant, but the onset of current stroke takes priority.  Option B: A complete history is not possible in emergency care.  Option D: Upcoming surgical procedures will need to be delay if t-PA is administered. 4. Answer: 3. Blood pressure Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to physician and is specific to the client’s ischemic tissue needs and risks ofbleeding from treatment. Other vital signs are monitored, but the priority is blood pressure. 5. Answer: 2. Pupil size and pupillary response It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.  Option A: Cholesterol level is an assessment to be addressed for long- term healthy lifestyle rehabilitation.  Option C: Bowel sounds need to be assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours.  Option D: An echocardiogram is not needed for the client with a thrombotic stroke. 6. Answer: 3. Dissolved emboli. Thrombolytic therapy is used to dissolve emboli and reestablish cerebral perfusion. 7. Answer: 1. An oral anticoagulant medication. Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge versus intravenous.  Option B: Beta blockers slow the heart rate and lower the blood pressure.  Option C: Anti-hyperuricemic medication is given to clients with gout.  Option D: Thrombolytic medication might have been given at initial presentation but would not be a drug prescribed at discharge. 8. Answer: 1. A 55-year-old African American male. African Americans have twice the rate of CVA’s as Caucasians; males are more likely to have strokes than females except in advanced years.  Option B: Oriental’s have a lower risk, possibly due to their high omega-3 fatty acids.  Option D: Pregnancy is a minimal risk factor for CVA. 9. Answer: 3. A blood pressure of 220/120 mmHg. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel in the cranium.  Option A: High blood glucose levels could predispose a patient to ischemic stroke, but not hemorrhagic.  Option B: Bruit in the carotid artery would predispose a client to an embolic or ischemic stroke.  Option D: Cancer is not a precursor to stroke. 10. Answer: 3. The assistant places her hand under the client’s right axilla to help him/her move up in bed. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety. Options A, B, and D: All the other actions are appropriate. 1. Clients with chronic illnesses are more likely to get pneumonia when which of the following situations is present? 1. Dehydration 2. Group living 3. Malnutrition 4. Severe periodontal disease 2. Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows pneumonia to develop? 1. Atelectasis 2. Bronchiectasis 3. Effusion 4. Inflammation 3. Which of the following organisms most commonly causes community-acquired pneumonia in adults? 1. Haemiphilus influenzae 2. Klebsiella pneumoniae 3. Streptococcus pneumoniae 4. Staphylococcus aureus 4. An elderly client with pneumonia may appear with which of the following symptoms first? 1. Altered mental status and dehydration 2. Fever and chills 3. Hemoptysis and dyspnea 4. Pleuritic chest pain and cough 5. When auscultating the chest of a client with pneumonia, the nurse would expect to hear which of the following sounds over areas of consolidation? 1. Bronchial 2. Bronchovesicular 3. Tubular 4. Vesicular 6. A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests? 1. ABG analysis 2. Chest x-ray 3. Blood cultures 4. sputum culture and sensitivity 7. A client with pneumonia develops dyspnea with a respiratory rate of 32 breaths/minute and difficulty expelling his secretions. The nurse auscultates his lung fields and hears bronchial sounds in the left lower lobe. The nurse determines that the client requires which of the following treatments first? 1. Antibiotics 2. Bed rest 3. Oxygen 4. Nutritional intake 8. A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will be discharged today. Which of the following physical findings would lead the nurse to believe it is appropriate to discharge this client? 1. Continued dyspnea 2. Fever of 102*F 3. Respiratory rate of 32 breaths/minute 4. Vesicular breath sounds in right base 9. The right forearm of a client who had a purified protein derivative (PPD) test uploads/Geographie/ study-guide 7 .pdf