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1 Post for Oct 30-Nov 5 on Sun Nov 06, 2011 6:00 pm

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Chapter 16: Cerebrovascular Accident
Application Exercises Answer Key
Scenario: An older adult female client is brought to the emergency department after she fell from her chair during breakfast. The client has a Glasgow Coma Scale score of 5 and her blood pressure is 150/96 mm Hg, respirations are 16/min, pulse is 56/min, and a temperature of 38.3° C (101° F). Her admitting medical diagnosis is a suspected CVA. A CT scan is scheduled for the client.

1. Based on the CT results, the client is diagnosed with a right-hemispheric CVA of embolic origin. Which of the following neurological deficits should the nurse expect to find? (Select all that apply.)
_____Aphasia (receptive or expressive)
_____Right hemiplegia or hemiparesis
X___ Lack of awareness of deficits
X___ Impulse control difficulty
_____Slow, cautious behavior
X___ Left hemiplegia or hemiparesis
A client who has experienced a right-hemispheric CVA will experience left-sided hemiplegia
or hemiparesis along with impulsive behavior and a lack of awareness of deficits. This client
poses a safety problem as she may impulsively respond to the urge to use the restroom or get
a drink of water from across the room without assistance and fall. This is because she does
not recognize her neurological deficits. Aphasia, right hemiplegia or hemiparesis and slow,
cautious behavior is seen in clients who have had a left-hemispheric CVA.
NCLEX® Connection: Physiological Adaptation, Pathophysiology

2. The client is diagnosed with left homonymous hemianopsia. Which of the following actions is
appropriate for the nurse to include in the client’s plan of care?
A. Teach the client to scan to the right to see objects on the right side of her body.
B. Place the client’s bedside table on the right side of the bed.
C. Orient the client to the food on her plate using the clock method.
D. Place the client’s wheelchair on her left side.
A client who has left homonymous hemianopsia has lost the left visual field of both eyes.
She is unable to visualize anything to the left of midline of her body. Placing the client’s
bedside table on the right side of her bed will allow her to easily visualize items on the table.
Scanning to the right will decrease the client’s field of vision, the clock method of food
placement will be ineffective since only half of the plate can be seen, and the wheelchair
should be placed on the right or unaffected side of the client.
NCLEX® Connection: Physiological Adaptation, Illness Management

3. When the client resumes dietary intake, which of the following actions should the nurse take? (Select all that apply.)
X___ Have the suction equipment available for use.
X___ Thicken liquids using a commercial thickener.
X___ Place food on the client’s unaffected side of her mouth.
_____Assign an assistive personnel to slowly feed the client.
_____Teach the client to swallow with her neck flexed.
X Discontinue feeding the client if choking occurs.
The nurse caring for this client should have suction equipment available in case the client
begins to choke. The client should be given thickened liquids, which are easier to swallow.
Placing food on the unaffected side of the client’s mouth will allow her to have better
control of the food and again, reduce the risk of aspiration. Due to the risk of aspiration,
an assistive personnel should not be assigned to the client because the client’s swallowing
ability needs to be assessed and suctioning may be needed if choking occurs. The client
should also be taught to flex her neck, tucking the chin down and under, to close the
epiglottis during swallowing. If choking during feedings occurs, the client should be made
NPO and the provider should be notified.
NCLEX® Connection: Physiological Adaptation, Illness Management

4. A nurse has been assigned a client who is diagnosed with global aphasia (both receptive and
expressive). Which of the following interventions are appropriate to include in the client’s plan
of care? (Select all that apply.)
X___ Speak to the client at a slower rate.
X___ Look directly at the client when speaking.
X___ Allow plenty of time for the client to answer.
_____Complete sentences that the client cannot finish.
X___ Give instructions one step at a time.
_____Speak louder if the client does not understand.
Clients who have global aphasia will have difficulty with both speaking and understanding
speech. Strategies that can enhance understanding are speaking at a slower rate, looking
at the client when speaking, giving instructions one step at a time, and allowing the client
time to answer questions without trying to answer for him. Speaking louder to a client with
receptive aphasia who does not have a hearing deficit will not enhance his understanding.
NCLEX® Connection: NCLEX Connection, Physiological Adaptation, Illness Management

Chapter 44: Blood and Blood Product Transfusions
Application Exercises Answer Key
1.Fill in the types of blood that each of the following clients may receive.
Blood Type Compatiiable Blood Type
1. A+ A+, A-, O+, O-
2. A- A-, O-
3. B+ B+, B-, O+, O-
4. B- B-, O-
5. AB+ AB+, AB-, A+, A-, B+, B-, O+, O-
6. AB- AB-, A-, B-, O-
7. O+ O+, O-
8. O- O-

® Connection: Pharmacological and Parenteral Therapies, Blood and Blood Products

2. The nurse should remain with the client during the first 15 min of a blood transfusion to
A. verify the blood being transfused.
B. assess for an adverse reaction.
C. explain the procedure to the client.
D. obtain consent for the blood transfusion.
Assessing for a blood reaction typically occurs within the first 15 min of the transfusion.
Verifying the blood, explaining the procedure, and obtaining consent should all be done
prior to administrating the blood.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Blood and Blood Products

3. What actions should a nurse take if there is a possible transfusion reaction? (Select all that apply.)
X___ Stop the transfusion.
X___ Send the blood bag and IV tubing to the blood bank for analysis.
X___ Maintain an IV infusion with 0.9% sodium chloride.
X___ Notify the primary care provider.
_____Obtain blood cultures.
When a possible transfusion reaction is suspected, the nurse should stop the infusion, send the
blood bag and IV tubing to the blood bank for analysis, maintain an IV infusion with 0.9%
sodium chloride, and notify the provider. Blood and urine specimens are usually obtained to
determine hemolysis, but blood cultures are not routinely done unless sepsis is suspected.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Blood and Blood Products

4. A nurse is monitoring a client who began receiving a unit of blood 10 min ago. Which of the
following should pose an immediate concern for a nurse? (Select all that apply.)
_____Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F)
posttransfusion
X___ Dyspnea
X___ Restlessness
_____Heart rate increase: 74/min pretransfusion, 81/min post-transfusion
X___ Client report of itching
X___ Flushed appearance
Dyspnea, restlessness, report of itching and a flushed appearance may indicate a transfusion
reaction. A slight increase in heart rate and temperature is an expected finding.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Blood and Blood Products

Chapter 46: Leukemia and Lymphoma
Application Exercises Answer Key
1. A client who has leukemia develops thrombocytopenia following chemotherapy. Based on this
specific finding, which of the following nursing interventions is the priority?
A. Encourage the client to turn, cough, and deep breathe every 2 hr.
B. Monitor the client’s temperature every 4 hr.
C. Monitor the client’s platelet counts.
D. Encourage the client to take frequent rest periods throughout the day.
The greatest risk to the client who has thrombocytopenia is bleeding. Bleeding precautions
are generally implemented for platelet counts less than 50,000/mm3. Encouraging the client
to turn, cough, and deep breath, monitoring the client’s temperature, and encouraging
frequent rest periods are important, but none of them is the priority at this time.
NCLEX® Connection: Reduction of Risk Potential, Potential for Alterations in Body Systems

2. Which of the following nursing interventions and client instructions are appropriate in caring for a client who has pancytopenia? (Select all that apply and identify the rationale for each chosen option.)
X___ Restrict fresh fruits and vegetables in the diet.
_____Restrict visitors.
_____Insert a Foley urinary catheter to monitor intake and output.
_____Restrict fluids.
X___ Report low-grade temperature.
X___ Hold firm pressure for 5 min following necessary venipunctures.
_____Report an ANC of 2,500/mm3.
X___ Administer epoetin alfa (Procrit) as prescribed.
Fresh fruits and vegetables pose a risk for introduction of bacteria into the gastrointestinal
systems. A low-grade temperature may represent an immune response to an infection
for clients who are immunosuppressed. Clients are at greater risk for bleeding due to
low platelet counts. Firm pressure for longer periods of time is indicated following
invasive procedures. Anemia is a probable consequence of the disease and/or treatment.
Administration of a colony stimulating factor, such as epoetin alfa, can be vital in RBC
production to counter disease/treatment-induced anemia. An absolute neutrophil count
(ANC) less than 2,000/mm3 increases the risk of infection. Visitors should wear a protective
mask and practice good hand hygiene. Only individuals who have a communicable disease
should be restricted. There is no reason to insert an indwelling urinary catheter or restrict
fluids.
NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic

3. A client’s platelet count is 10,000/mm3. Based on this laboratory value, which of the following is the priority nursing assessment?
A. Level of consciousness
B. Skin turgor
C. Bowel sounds
D. Breath sounds
The greatest risk to the client is spontaneous bleeding, including the risk for a fatal cerebral
bleed, due to a platelet count less than 20,000/mm3. A change in level of consciousness can
be an early sign of cerebral hemorrhage. Assessing skin turgor, bowel sounds, and breath
sounds are not priority actions.
NCLEX® Connection: Reduction of Risk Potential, System Specific Assessment

4. Match the following.
C Hodgkin’s lymphoma A. Most common leukemia in adults
A Acute myelogenous leukemia (AML) B. Most cases are in adults over the age of 60
B Chronic lymphocytic leukemia (CLL) C. Reed-Sternberg cells
D Non-Hodgkin’s lymphoma D. Can be caused by radiation
Reed-Sternberg cells are significant for Hodgkin’s lymphoma. The most common leukemia
in adults is AML. Chronic lymphocytic leukemia is an uncommon form of leukemia that
may develop in adults over age 60. Non-Hodgkin’s lymphoma can be caused by radiation.
NCLEX® Connection: Physiological Adaptation, Pathophysiology

Chapter 43: Hematologic Diagnostic Procedures
Application Exercises Answer Key
1. A nurse is admitting a client in the emergency department who reports thirst, tiredness, and difficulty
concentrating. Upon assessment, the nurse notices that the client is pale and has heart palpitations. The nurse suspects that the client may be anemic. Which of the following tests should the nurse anticipate to be ordered?
A. International normalized ratio (INR)
B. Platelet count
C. WBC count
D. Hemoglobin
An Hgb test is ordered to check for anemia. INR, platelet count, and WBC count are not
indicated for anemia.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests

2. A nurse is caring for a client who has hemophilia. Which of the following tests should the nurse anticipate to be ordered to check for this diagnosis?
A. RBC
B. WBC
C. aPTT
D. INR
PTT checks the clotting factors and is indicated for a client who has hemophilia. RBC, WBC,
and INR are not indicated for this client.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests

3. A nurse is providing teaching for a client who needs to have a bone marrow aspiration of the iliac crest. Which of the following statements made by the client indicates a need for further teaching?
A. “Cancer can be detected in the fluid being tested.”
B. “I will feel a heavy pressure sensation in my hip bone.”
C. “The need for antibiotics can be determined with this test.”
D. “I will be awake during the procedure.”
The fluid from a bone marrow aspiration is not being tested for the presence of an infection
and the need for antibiotics. Cancer can be detected in the fluid; the client will feel a heavy
pressure in the hip bone; and the client will be awake during the procedure.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests

5 Signs and Symptoms to increasing ICP
Change in LOC: drowsiness to coma (use Glasgow coma scale)
Headache/Nausea/vomiting
Cardiovascular changes: bradycardia, hypertension, increased pulse pressure, dysrhythmias
Respiratory changes: change in rate, depth, and pattern
Seizures
Lemone RN,DSN,FAAN, Priscilla; Burke RN,MS, Karen, Clinical Handbook Medical Surgical Nursing, Critical Thinking in Client Care, Second Edition

three positions that are contraindicated in a patient with increased ICP
Any position that is flat
Trendelenburg
Or with head turned to a side

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