Mark the letter of the letter of choice then click on the next button. Answer will be revealed after each question. No time limit to finish the exam. Good luck!
Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.
Administer lorazepam (Ativan) 1 mg IV.
Turn the patient to the side and protect airway.
Assess level of consciousness during and immediately after the seizure.
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Acute pain related to biologic and chemical factors
Anxiety related to change in or threat to health status
Hopelessness related to deteriorating physiological condition
Risk for Side effects related to medical therapy
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Determine the level at which the patient has intact sensation.
Assess the level at which the patient has retained mobility.
Check blood pressure and pulse for signs of spinal shock.
Monitor respiratory effort and oxygen saturation level.
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The student enters the room without putting on a mask and gown.
The student instructs the family that visits are restricted to 10 minutes.
The student gives the patient a warm blanket when he says he feels cold.
The student checks the patient’s pupil response to light every 30 minutes.
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Administer an acetaminophen suppository.
Notify the physician immediately.
Recheck vital signs in 1 hour.
Reschedule patient’s physical therapy.
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“You should avoid consumption of all forms of alcohol.”
“Wear you medical alert bracelet at all times.”
“Protect your loved one’s airway during a seizure.”
“It’s OK to take over-the-counter medications.”
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Place on the hospital alcohol withdrawal protocol.
Transfer to radiology for a CT scan.
Insert a retention catheter to straight drainage.
Give phenytoin (Dilantin) 100 mg PO.
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“I will avoid exercise because the pain gets worse.”
“I will use heat or ice to help control the pain.”
“I will not wear high-heeled shoes at home or work.”
“I will purchase a firm mattress to replace my old one.”
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A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose
A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured berry aneurysm.
A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due
A 65-year-old patient with a astrocytoma who has just returned to the unit after having a craniotomy
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Assess patient’s respiratory status every 4 hours.
Take patient’s vital signs and record every 4 hours.
Monitor nutritional status including calorie counts.
Have patient turn, cough, and deep breathe every 3 hours.
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Complaints of numbness and tingling
Facial weakness and difficulty speaking
Rapid heart rate of 102 beats per minute
Shallow respirations and decreased breath sounds
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Position the patient sitting up in bed before you feed her.
Check the patient’s gag and swallowing reflexes.
Feed the patient quickly because there are three more waiting.
Suction the patient’s secretions between bites of food.
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“Your wife was not admitted within the time frame that alteplase is usually given.”
“This drug is used primarily for patients who experience an acute heart attack.”
“Alteplase dissolves clots and may cause more bleeding into your wife’s brain.”
“Your wife had gallbladder surgery just 6 months ago and this prevents the use of alteplase.”
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Risk for Injury related to altered mobility
Imbalanced Nutrition, Less Than Body Requirements
Impaired Adjustment to Spinal Cord Injury
Poor Body Image related to immobilization
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Decreased Cardiac Output related to poor myocardial contractility
Caregiver Role Strain related to continuous need for providing care
Ineffective Therapeutic Regimen Management related to poor patient memory
Risk for Falls related to patient wandering behavior during the night
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Fatigue related to disease state
Activity Intolerance due to generalized weakness
Impaired Physical Mobility related to neuromuscular impairment
Self-care Deficit related to fatigue and neuromuscular weakness
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A 34-year-old patient newly diagnosed with multiple sclerosis (MS)
A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS)
A 56-year-old patient with Guillain-Barre syndrome (GBS) in respiratory distress
A 25-year-old patient admitted with CA level spinal cord injury (SCI)
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Complete admission assessment.
Set up oxygen and suction equipment.
Place a padded tongue blade at bedside.
Pad the side rails before patient arrives.
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The student instructs the patient to sit up straight, resulting in the patient’s puzzled expression.
The student moves the patient’s tray to the right side of her over-bed tray.
The student assists the patient with passive range-of-motion (ROM) exercises.
The student combs the left side of the patient’s hair when the patient combs only the right side.
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A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching
A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching
A 59-year-old with Parkinson’s disease who will need a swallowing assessment before breakfast
A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain
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Administer the ordered acetaminophen (Tylenol).
Check the Foley tubing for kinks or obstruction.
Adjust the temperature in the patient’s room.
Notify the physician about the change in status.
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The gums appear enlarged and inflamed.
The white blood cell count is 2300/mm3.
Patient occasionally forgets to take the phenytoin until after lunch.
Patient wants to renew his driver’s license in the next month.
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The NA assists the patient to ambulate to the bathroom and back to bed.
The NA reminds the patient not to look at his feet when he is walking.
The NA performs the patient’s complete bath and oral care.
The NA sets up the patient’s tray and encourages patient to feed himself.
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Administer codeine 15 mg orally for the patient’s headache.
Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.
Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.
Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure
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The patient does not recognize family members.
The blood glucose level is 234 mg/dL.
The patient complains of a continued headache.
The daily weight has increased 1 kg.
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A 28-year-old newly admitted patient with spinal cord injury
A 67-year-old patient with stroke 3 days ago and left-sided weakness
An 85-year-old dementia patient to be transferred to long-term care today
A 54-year-old patient with Parkinson’s who needs assistance with bathing
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Check for improvement in resident memory after medication therapy is initiated.
Use the Mini-Mental State Examination to assess residents every 6 months.
Assist residents to toilet every 2 hours to decrease risk for urinary intolerance.
Develop individualized activity plans after consulting with residents and family.
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Check the patient’s skin for pressure form device.
Assess the patient’s neurologic status for changes.
Observe the halo insertion sites for signs of infection.
Clean the halo insertion sites with hydrogen peroxide.
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Assist patient to reposition every 2 hours.
Reapply pneumatic compression boots.
Remind patient to perform active ROM.
Check extremities for redness and edema.
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Stroke the patient’s inner thigh.
Pull on the patient’s pubic hair.
Initiate intermittent straight catheterization.
Pour warm water over the perineum.
Tap the bladder to stimulate detrusor muscle.
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Document the onset time, nature of seizure activity, and postictal behaviors for all seizures.
Administer phenytoin (Dilantin) 200 mg PO daily.
Teach patient about the need for good oral hygiene.
Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.
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Avoid foods that contain tyramine, such as alcohol and aged cheese.
Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.
Abortive therapy is aimed at eliminating the pain during the aura.
A potential side effect of medications is rebound headache.
Complementary therapies such as relaxation may be helpful.
Continue taking estrogen as prescribed by your physician.
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Check for orthostatic changes in pulse and bloods pressure.
Monitor for improvement in tremor after levodopa (L-dopa) is given.
Remind the patient to allow adequate time for meals.
Monitor for abnormal involuntary jerky movements of extremities.
Assist the patient with prescribed strengthening exercises.
Adapt the patient’s preferred activities to his level of function.
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