Unit Exam 3 Capstone Study Guide with Answers (98 Solved Questions)

Name: Unit Exam 3 Capstone Study Guide with Answers (98 Solved Questions)
Brand: Academic Documents Platform
Price: 4.99 USD
Availability: InStock
Author: Joseph Martinez

Unit Exam 3 Capstone Study Guide with Answers gives you insight into exam patterns with actual previous tests.

Joseph Martinez

Contributor

4.4

102

about 2 months ago

Preview (7 of 20)

UNIT EXAM 3 STUDY GUIDE
Trauma – (Client in trauma has absent breath sounds what this mean?
Pneumothorax)
The emergency department nurse is assessing a client who has sustained a blunt
injury to the chest wall.
Which finding indicates the presence of a pneumothorax in this client?
-Diminished breath sounds
Thoracentesis causing pneumothorax (Signs and symptoms of pneumothorax):
-Tracheal deviation
-Sensation of air hunger
-Cyanosis of oral mucous membranes
Zafirlukast
Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test
does the nurse expect to
be prescribed before the administration of this medication?
Liver function tests.
Albuterol/Ipratropium
The nurse is caring for a client receiving an albuterol/ipratropium nebulized
breathing treatment. Which
report from the client should the nurse note as an expected side effect of this
combination?
I feel like my heart is racing.
Head Injury (craniotomy: Head circumference (measure head)
The nurse is assessing the motor and sensory function of an unconscious client
who sustained a head injury. The nurse should use which technique to test the
client's peripheral response to pain?
Nail Bed pressure
Increased intracranial Pressure- early sign: headache (from Saunders book)
A nurse is teaching family members of a client with a concussion about the early
signs of increased cranial pressure, ICP. Which of the following would the nurse
cite as early signs of ICP?
headache and vomiting
The nurse is monitoring a 3-year-old child for signs and symptoms of increased
intracranial pressure
lOMoARcPSD|12950611

(ICP) after a craniotomy. The nurse plans to monitor for which early sign or
symptom of increased ICP?
Vomiting
What is one of the earliest signs of increased intracranial pressure ICP?
decreased level of consciousness (LOC)
A mother arrives at the emergency department with her 5-year-old chills and states
that the child fell off a
bunk bed. A head injury is suspected. The nurse checks the child's airway status
and assesses the child for
early and late signs of ICP.Which is the late sign?
Bradycardia
The nurse is reviewing the record of a child with ICP and notes that the
child has exhibited signs of decerebrate posturing. On assessment of the child,
the nurse expects to note which characteristic of this type posturing?
Rigid extension and pronation of the arms and legs
A client recovering from a head injury is participating in care. The nurse
determines that the client understands measures to prevent elevations in ICP if
the nurse observes the client doing which activity?
Exhaling during repositioning
1
The nurse is caring for the client with ICP as a result of a head injury/ the
nurse would note which trend in
VS if the intracranial pressure is rising?
Increasing temp, decreasing pulse, decreasing respirations, increasing blood
pressure
Seizure (Continue Monitoring when pt is experiencing a seizure turns
cyanotic)
A child becomes cyanotic during a generalized tonic-clonic seizure. What is the
most appropriate action
by the nurse?
Continuing to observe the seizure
The nurse is creating a plan of care for a child who is at risk for seizures. Which

interventions apply if the
child has a seizure?
-Time the seizure
-Stay with the child
-Move the furniture away from the child
The nurse is caring for a client who begins to experience seizure activity while in
bed. Which actions
should the nurse take? (SATA)
-Loosening restrictive clothing
-Removing the pillow and raising padded side rails
-Positioning the client to the side, if possible with the head flexed forward
The nurse is instituting seizure precautions for a client who is being admitted from
the emergency
department. Which measures should the nurse include in planning for the client’s
safety? (SATA)
-Padding the side rails of the bed
-Placing an airway at the bedside
-Placing oxygen and suction equipment at the bedside
-Flushing the intravenous catheter to ensure that the site is patent
The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the
plan of care, the nurse
identifies seizure precautions and documents which items need to be placed at the
child's bedside?
Suctioning equipment and oxygen
VP Shunt- (What to watch for: Infection)
A nurse is providing discharge teaching to parents whose infant had a
ventriculoperitoneal shunt
placement for the treatment of hydrocephalus. Which of the following statements
by the parents indicates
an understanding of the teaching?
"We will notify the doctor right away if he has a fever."
Important to communicate to the surgeon after ventriculoperitoneal shunt is
placed?
3-year-old returned ped unit= The right pupil is 1mm larger than the left pupil
Guillain Barre Syndrome (Monitor Respiratory)

Loading page 4...

A 27-year-old patient is hospitalized with new onset of Guillain-Barre syndrome.
The most essential
assessment for the nurse to carry out is
observing respiratory rate and effort.
The nurse is admitting a client with Guillain-Barre syndrome to the nursing
unit. The client has
complaints of inability to move both legs and reports a tingling sensation
above the waistline. Knowing
the complications of the disorder, the nurse should bring which most essential
items into the client’s
room?
Electrocardiographic monitoring electrodes and intubation tray
2
A client with Guillain-Barre syndrome has ascending paralysis and is intubated
and recovering mechanical ventilation. Which strategy should the nurse
incorporate in the plan of care to help the client cope with this illness?
Providing information, giving positive feedback, and encouraging relaxation
The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome.
Which past medical history finding makes the client most at risk for this disease?
Respiratory or gastrointestinal infection during the previous month
Meningitis (Brudzinski sign: Neck flexion pick the one with neck)
The nurse is assessing a client for meningeal irritation and elicits a positive
Brudzinski's sign. Which
finding did the nurse observe?
The client passively flexes the hip and knee in response to neck flexion and
reports pain in the vertebral column.
The nurse is evaluating the status of a client who had a craniotomy 3 days ago.
Which assessment finding
would indicate that the client is developing meningitis as a complication of
surgery?

Loading page 5...

A positive Brudzinski’s sign
The nurse notes documentation that a child is exhibiting an inability to flex leg
when the thigh is flexed
anteriorly at the hip. Which condition does the nurse suspect?
Meningitis
A lumbar puncture is performed on a child suspected to have bacterial meningitis,
and cerebrospinal fluid
is obtained for analysis. The nurse reviews the results of the CSF analysis and
determines which results
would verify the diagnosis?
Cloudy CSF, elevated protein, and decrease glucose levels
The nurse is planning care for a child with acute bacterial meningitis. Based on the
mode of transmission
of this infection, which precautionary intervention should be included in the plan
of care?
Maintain respiratory isolation precautions for at least 24hrs after the
initiation of antibiotics
Stroke (on the right side of the brain what would you see? Answers with the
left side of the body)
Left sided neglect, paralyzed left side, hemiplegia
The nurse is assigned to care for a client with complete right-sided hemiparesis
from stroke (brain attack).
Which characteristics are associated with this condition? (SATA)
-The client is aphasic
-The client has weakness on the right side of the body
-The client has weakness on the right side of the face and tongue
When caring for a patient with a new right-sided homonymous hemianopsia
resulting from a stroke,
which intervention should the nurse include in the plan of care?
Place objects needed on the patients left side.
A 73-year-old patient with a stroke experiences facial drooping on the right side
lOMoARcPSD|12950611

Loading page 6...

and right-sided arm and
leg paralysis. When admitting the patient, which clinical manifestation will the
nurse expect to find?
Difficulty comprehending instructions
Risk factors for stroke (SATA): -High blood pressure -TIA (transient
ischaemic attack)
-Smoking -Use of oral contraceptives
3
The nurse is assessing the adaptation of a client to changes in functional
status after a stroke. Which
observation indicates to the nurse that the client is adapting most
successfully?
Consistently uses adaptive equipment in dressing self
Myasthenia gravis (spread chores throughout day/ take breaks)
The nurse is teaching a client with Myasthenia Gravis about the prevention of
Myasthenic and cholinergic
crisis. Which client activity suggests that teaching is most effective?
Taking medications as scheduled
A client with Myasthenia Gravis has become increasingly weaker. The
primary health care provider prepares to identify whether the client is reacting to
an overdose of the medication (cholinergic crisis) or an increasing severity of the
disease (myasthenic crisis). An injection of edrophonium is administered. Which
finding would indicate that the client is in a cholinergic crisis?
A temporary worsening of the condition
Multiple Sclerosis (Oxybutynin “I still get up at night to pee”
The home health nurse is visiting a client with a diagnosis of multiple sclerosis.
The client has been
taking oxybutynin (Ditropan XL). The nurse evaluates the effectiveness of the
medication by asking the
client which assessment question?
"Are you getting up at night to urinate?"
When obtaining a health history and physical assessment for a 36-year-old
female patient with possible
multiple sclerosis (MS), the nurse should

Loading page 7...

6 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

AI Assistant

Document Details

Subject

Other Exams & Certifications

Unit Exam 3 Capstone Study Guide with Answers (98 Solved Questions)

Study Now!

Document Details

Related Documents

Wiley Series 57 Securities Licensing Exam Review 2020 + Test Bank (2020)

Police Officer Exam For Dummies, 2nd Edition (2022)

California Real Estate License Express: All-in-One Review and Testing (2020)

ACFT For Dummies (2020)

Securities Industry Essentials Exam 2023-2024 For Dummies (2022)

College Admission 101: Expert Advice for the New Challenges in Admissions, Testing, Financial Aid, and More (2022)

Beautiful Union Study Guide: A Practical Companion for Deep Reflection, Good Conversation, and Tough Questions You Really Want to Ask (2023)

Maryland Home Improvement Practice Exam with Answers (194 Solved Questions)

Carolyn Cross Assessment Mine Pracitce Exam with Answers (125 Solved Questions)

IICL Container Inspector's Pracice Exam with Answers (80 Solved Questions)