NURS480 Comprehensive Practice Exam With Answers (189 Solved Questions)

Name: NURS480 Comprehensive Practice Exam With Answers (189 Solved Questions)
Brand: Chamberlain College of Nursing
Price: 4 USD
Availability: InStock
Author: Logan King

Improve your answering techniques with NURS480 Comprehensive Practice Exam With Answers, featuring past papers and model solutions.

Logan King

Contributor

4.3

4 months ago

Preview (16 of 81)

EXAM 3
In planning for discharge planning for a client with bacterial meningitis, the nurse
will 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 fluids
3. Take all of the antibiotics until gone.
NURS 480 EXAM 1–3 WITH SATISFIED SOLUTIONS

4. Incorporate regular exercise with an active range of motion. - 3. Take all of the
antibiotics until gone.
The client should be instructed to complete all antibiotics until they are completely
gone. Failure to complete antibiotics may lead to re-infection and may spread
causing endocarditis and other infections in the body, especially if the bacteria
were 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 members
receive prophylactic antibiotics, but will be ordered according to the bacterial
strain and health care provider (HCP) recommendations. It is important to eat a
good diet, but the most important will be taking prescribed antibiotics. While
returning to exercise is important, gradual increase should be performed, and the
answer selection for exercise was not as important as prescribed antibiotics.
The nurse is assessing the central stimulus function of an unconscious client in
the intensive care unit. The nurse should plan to use which technique to test the
client'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. Supraorbital
ridge pressure by applying pressure on the orbital rim is indicated for central
stimulus assessment. Sternal rub is usually not indicated via best practices.
Pressure on the nail bed represents testing painful stimuli for motor testing on
peripheral nerves. Calling out loudly is not an assessment technique for central
stimulus function. There are two anatomic locations for pain stimulus: centrally
and peripherally. Central involves trapezious pinch or supraorbital pressure

whereas peripheral stimuli are applied to extremities. Responses may infer
damage to the brain or specific brain areas.
A client is admitted for observation following a motor vehicle accident that
occurred on the way to the client's daughter's wedding. The next morning, instead
of asking about the wedding, the client tells the nurse "I have to leave now since
the wedding is in a few minutes." The client then becomes agitated when the nurse
re-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 neurological
assessment 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 which
includes restlessness, agitation, headache, and pupil changes.
A client is taking felbamate (Felbatol) for seizures and displays symptoms of
pancytopenia based on which assessment findings? (Select all that apply)
1. Sore throat
2. Epistaxis
3. Skin rash
4. Gingival hyperplasia - 1. Sore throat
2. Epistaxis

Pancytopenia symptoms while taking felbamate include fever, sore throat, flu-like
feeling, and may exhibit increased bleeding with reduced platelet count (epitaxis).
Skin rash may not indicate pancytopenia. Gingival hyperplasia is an adverse affect
of anticonvulsants like phenytoin, but is not a symptom of pancytopenia.
Pancytopenia affects red cells, white cells, and platelets and represents bone
marrow'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 with
antacids and will lower phenytoin absorption. Clients on contraceptive hormone
therapy may need to use alternative forms of non-hormonal contraceptives while
on phenytoin sodium (Dilantin).
The nurse is caring for a client who is unconscious who requires enteral feedings
through a nasogastric tube. Which action takes priority when managing enteral
feedings?
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.

4. Keep the formula warm by setting in hot water 30 minutes prior to
administration. - 3. Keep the client in semi-fowlers position.
It is most important to maintain a semi-flowlers position with nasogastric
feedings to prevent aspiration. While daily weights may be important, protecting
the airway and lungs from aspiration is more important. Having sterile water and
supplies are not necessary since the management is with clean not sterile
procedure. The formula should be room temperature and should never be heated
prior to administration.
The nurse will collaborate with the interdisciplinary team on communication assist
with a client with expressive aphasia. The team decided on which intervention to
help 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 client
driven. - 4. Make sure all staff assist the client with use of a picture board which
is client driven.
Expressive aphasia clients may understand what is heard or written, but they may
not be able to verbally communicate their needs. A picture or communication
board helps the client as the client can point to or direct others towards objects
on the board for wants and needs. Speaking loudly or slowly is not therapeutic for
communication and may diminish the client's dignity. Having staff to be the only
ones 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 be
encouraged to express needs and wants through therapeutic means.

Loading page 6...

The nurse is caring for a client with increased intracranial pressure. Which
respiratory 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 the
result of deterioration of neural control of respirations, which is controlled by the
brain stem. Deterioration and pressure produce irregular respiratory patterns.
Nasal flaring and rapid shallow respirations are a sign of respiratory distress
which may not have root causes because of neurological changes.
The emergency department nurse receives a client with an ischemic stroke, and
prepares to administer tissue plasminogen activator (t-PA). What question should
the 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 of
onset of stroke.
Timing of onset of stroke is important when receiving t-PA. Studies indicate that
clients should receive the thrombolytic medication within 3 - 4.5 hours after the
onset of a stroke for best outcomes. While asking about speech changes is
important, it is more important to establish time frame of stroke onset. Other
questions are not important as the emergent need is to determine if the client is a
candidate for t-PA administration.

Loading page 7...

A client with trigeminal neuroalgia returns to the clinic for follow-up. Which
assessment is most important for the nurse to perform for the client with
trigeminal neuroalgia?
1. Skin temperature
2. Determining areas of pain through palpation
3. Examination of dentition
4. Perform cranial nerve IX and X assessment - 3. Examination of dentition
Assessment of teeth and gums are important because dental care is often not
performed for fear of pain associated with the oral care. Skin temperature and
determining pain on palpation are not useful, and palpation for pain may trigger
more intense pain and should be avoided. Cranial nerve IX and X are not affected
by trigeminal neuralgia (trigeminal nerve is V). Trigeminal nerves control
sensations in the face. Most pain is experienced in the upper or lower jaw and
runs in cycles
A nurse caring for a client with Guillain-Barré syndrome notifies the health care
provider of deteriorating condition. Which of the following assessment findings
indicate a worsening of Guillain-Barré syndrome?
1. Weakness
2. Paresthesia
3. Thick green respiratory sputum
4. Lower extremity pain - 3. Thick green respiratory sputum
Guillain-Barré is characterized by paralysis which ascends through the body
affecting the peripheral nervous system. Serious complications may occur as a
result of respiratory infection since respiratory center is affected and failure may

Loading page 8...

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 the
following 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 relieving
muscle spasms that frequently occur with MS. Baclofen does not reduce chances
of getting infections, it does not decrease depression, and sedation is an adverse
effect.
The nurse is caring for an 8 year-old client who is diagnosed with epilepsy
following an abnormal electroencephalogram (EEG). The parents are voicing
disbelief in the diagnosis and indicate they never witnessed a seizure. Which of the
following type of seizure will the nurse provide instruction for the parents?
1. Jacksonian seizure
2. Petit mal seizure
3. Grand mal seizure
4. Myoclonic seizure - 2. Petit mal seizure
Petit mall seizures are also called absent seizures since they may be observed
only 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

Loading page 9...

is necessary. They usually are found between 3 and 15 years of age. Jacksonian
seizure involves focal abnormal movements that usually begin in distal muscles
and progress to other adjacent muscles (Motor Seizure). They last around 20-30
seconds and would be noticeable by the parents. Grand mal seizures are
noticeable and the body may stiffen, jerk, shake, and loss of consciousness
occurs. Myoclonic seizures occur with sudden muscle jerking as if shocked by
electrical current, so the parents would have observed this type.
The nurse is preparing an instructional discharge plan for a client with damage to
cranial 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 is
clutter free and clear of obstacles.
Cranial nerve II is the optic nerve and visual center, so the nurse needs to ensure
that instruction on safe environment is provided. Speaking loudly may be
instruction for hearing (Cranial nerve VII). Cranial nerve X, XI, & XII are more
appropriate for answers C and D.
The nurse is caring for an unconscious client and performs passive range of
motion 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.

Loading page 10...

Passive range of motion maintains joint mobility and reduces the chances of
freezing 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 care
unit with a diagnosis of head trauma. The emergency room nurse reports the
client has increased intracranial pressure. Which assessment findings are the
most important for the nurse to monitor? (Select all that apply)
1. Urine output
2. Rate of respirations
3. Cerebral perfusion pressure
4. Systolic blood pressure - 3. Cerebral perfusion pressure
4. Systolic blood pressure
The systolic plus diastolic blood pressures are important and necessary in order
to monitor mean arterial pressure (MAP). The MAP is necessary to assess since it
reflects pressure required for brain perfusion with each cardiac cycle.The
intracranial pressure (ICP) and MAP will provide analysis of cerebral perfusion
pressure. While urine output, respiratory rate are important, the question is
focused on critical indicators associated with head trauma.
The nurse is instructing a client on the causes of Bell's palsy. What is the nurse's
best 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 malnutrition
4. It may be triggered from drug and alcohol addiction - 2. It's cause may be
unknown.

Loading page 11...

The exact cause of Bell's Palsy is unknown, but some studies suggest it may
include 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 with
malnutrition.
The evening nursing is caring for a client with new onset of myasthenia gravis. The
nurse expects to find which of the following assessment observations?
1. Hand tremors when lifting a gallon of milk.
2. Stronger hand grips and steadier gait
3. Pain and tingling to extremities
4. Blurred vision and unclear speech patterns - 4. Blurred vision and unclear
speech patterns
Myasthenia gravis is a chronic autoimmune neuromuscular disease that causes
weakness in skeletal muscles including those that control breathing and eye
movement. Antibodies block, alter, or destroy receptors for acetylcholine at the
neuromuscular junction which prevents muscular contraction. Vision changes,
difficulty swallowing, breathing, ptosis, speech, and peripheral weakness are
symptoms, and may worsen as the day progresses, so symptoms may be worse in
later times of the day. While tremors when lifting the weight of a gallon of liquid
may not be a cardinal sign, even though tremors may occur with profound
weakness that may occur while using muscles for small low weight tasks. Vision
and speech impairments are some of the first noticeable symptoms.
The nurse is caring for a client with spinal cord injury and is preparing
instructional plan for the client and family on autonomic dysreflexia. Which

Loading page 12...

teaching promotes the best measure to minimize occurrence of autonomic
dysreflexia?
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 bladder
catheterization at least every 4 hours.
The nurse should instruct the client and family to make sure the bladder is not full
since a full bladder may trigger an autonomic dysreflexia response, which may
lead to increased blood pressure and possible stroke. Nitroglycerin may be used
at the onset of autonomic dysreflexia for increased blood pressure. Some signs
are headache, flushed skin, or sweating above the spinal cord injury occurs. The
nitro past helps to bring blood pressure down quickly. Performing range of motion
does not lessen chances of autonomic reflexia.
Which cranial motor nerve controls the movement of the trapezius and
sternocleidomastoid muscles of the shoulder?
1. Abducens
2. Trigeminal
3. Spinal accessory
4. Glossopharyngeal - 3. Spinal accessory
A 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 central
nervous system (CNS) depression with complaints of increased lethargy and
confusion. The nurse provides further instruction on CNS depression after the
client discloses use of which of the following?

Loading page 13...

1. Alcohol
2. Furosemide
3. Metformin
4. Calcium - 1. Alcohol
Use of alcohol with phenytoin can increase CNS depression. The nurse should
provide further education if a client discloses the use of alcohol while taking
phenytoin.
The nurse is assessing a client who has been on phenytoin for 10 years. Which
characteristic finding is observed in clients with a long-term history of taking
phenytoin 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 can
cause gingival hyperplasia (excessive growth of gum tissue).
The nurse is caring for a client who was admitted 8 hours ago for a traumatic
brain injury. The client's Glasgow Coma Scale score was 15 upon arrival, but now
the 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.

Loading page 14...

4. Notify the healthcare provider immediately. - 4. Notify the healthcare provider
immediately.
The total Glasgow coma scale (GCS) highest score is 15, which is considered
normal brain activity. If the client's GCS is less than 8, the client is considered
neurologically unstable, a medical emergency, and will be placed in the intensive
care unit.
A client with Guillain-Barre syndrome will be receiving immunoglobulin therapy
(IVIG) and questions the nurse about the purpose of the treatment. Which
statement by the nurse is correct?
1. "The liquid portion of part of your blood called plasma, is removed and replaced
with healthy plasma to remove the antibodies that are harming your immune
system."
2. "Donated blood plasma that contains certain antibodies is given to provide your
body with the antibodies needed to fight infection."
3. "Intravenous corticosteroid treatment is administered to reduce nerve
inflammation associated with Guillain-Barre syndrome."
4. "Intravenous injection of synthetically made proteins that perform like human
antibodies to fight off harmful antigens." - 2. "Donated blood plasma that contains
certain antibodies is given to provide your body with the antibodies needed to fight
infection."
Immunoglobulin therapy is blood plasma donated by healthy donors given
intravenously to provide the body with the antibodies needed to fight infection.
High doses of immunoglobulin can impede the injurious antibodies that present
with GBS.

Loading page 15...

The nurse is caring for a client with a Glasgow coma scale of 5. What finding would
the nurse expect with a coma scale of 5?
1. The client is alert & oriented X 4
2. The client is alert but confused
3. The client is severely confused
4. The client is in a coma - 4. The client is in a coma
The total Glasgow coma scale (GCS) highest score is 15, which is considered
normal brain activity. If the client's GCS is less than 8, the client is considered
neurologically unstable, a medical emergency, and will be placed in the intensive
care unit. The GCS assesses best eye opening response, best verbal response, and
best 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 brain
injury. 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 for
increased intracranial pressure. Which is the most important for the nurse to
monitor following administration of mannitol?
1. Intake and output.
2. Pupillary response.
3. Changes in pulse pressure
4. Respiratory rate. - 1. Intake and output.
Which nursing diagnosis is appropriate for the client with Guillain-Barre
syndrome?
1. Impaired skin integrity
2. Risk for ineffective breathing pattern

Loading page 16...

13 more pages available. Scroll down to load them.

Preview Mode

100%

Study Now!

XY-Copilot AI

Unlimited Access

Secure Payment

Instant Access

24/7 Support

Document Chat

Document Details

University

Chamberlain College of Nursing

Subject

Nursing

NURS480 Comprehensive Practice Exam With Answers (189 Solved Questions)

Study Now!

Document Details

Related Documents

NURS480 Comprehensive Practice Exam With Answers (55 Solved Questions)

NURS480 Nursing Diagnosis Study Guide Practice Exam With Answers (250 Solved Questions)

Laboratory 8 Muscle Soreness Lab Manual

Case Diana

Identifying a Local Healthcare Economic Issue

Dashboard Metrics Evaluation 1 Dashboard Metrics E

NRP 563 DQ 2

NRP 563 DQ 7

Clinical Supervision Report Week 2

NU 185 Exam 5 Final

Company

Explore

Study Tools