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RN Adult Medical Surgical 2023 Proctored Exam
Total Questions : 97
Showing 10 questions, Sign in for moreA nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority?
Client comes to the ED reporting a headache that has lasted for 3 days. Reports pain is currently a 7 out of 10. Client appears pale and lethargic. Client also reports photophobia, malaise, nausea, and chills. Positive nuchal rigidity, lung sounds clear, heart sounds regular, hyperactive bowel sounds in all 4 quadrants. 18-gauge IV initiated in the left antecubital space and IV fluids started. Awaiting CT scan results.
- Temperature 39.2 C (102.6 F)
- Heart Rate 115/min
- Respiratory rate 12/min
- Blood pressure 98/64 mm Hg
- Oxygen saturation 94% on room air
A nurse is caring for a client who has just been admitted to the emergency department (ED).
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation
Rationale for Correct Choices
• Meningitis: The client’s high fever, chills, photophobia, nausea, and severe headache lasting several days strongly indicate meningitis. The presence of nuchal rigidity is a hallmark meningeal sign, supporting this diagnosis. The client’s tachycardia, lethargy, and borderline hypotension further signal a systemic inflammatory response consistent with infectious meningitis.
• Decrease environmental stimuli: Clients with meningitis are extremely sensitive to light and noise due to meningeal irritation, which can worsen headache and neurologic distress. Reducing stimuli helps reduce intracranial irritation, improves comfort, and can prevent worsening neurologic symptoms during the acute phase.
• Initiate neurological checks every 2 hr: Close monitoring detects early changes in level of consciousness, pupillary responses, and cranial nerve function caused by meningeal inflammation or rising intracranial pressure. Frequent neuro checks are vital for recognizing deterioration that requires immediate intervention.
• Temperature: Fever is a major indicator of infection severity in meningitis, and sustained hyperthermia increases metabolic demand and risk of neurologic injury. Monitoring temperature helps guide treatment effectiveness and determine the need for antipyretics or cooling measures.
• Vascular changes: Systemic infection can lead to changes such as tachycardia, hypotension, and prolonged capillary refill, signaling progression toward septic shock. Monitoring vascular status helps detect hemodynamic instability early in clients with meningitis.
Rationale for Incorrect Choices
• Hydrocephalus: Hydrocephalus typically presents with progressive neurological decline, altered mental status, and signs of increased intracranial pressure, not acute fever, nuchal rigidity, or photophobia. The client’s symptoms point toward infection rather than cerebrospinal fluid accumulation.
• Migraine headache: Migraines cause photophobia and nausea but do not usually produce high fever, chills, nuchal rigidity, or systemic symptoms. The presence of infection markers and meningeal signs makes migraine unlikely.
• Septic shock: Although the client is febrile and tachycardic, septic shock involves more pronounced hypotension and signs of end-organ dysfunction. The client’s symptoms indicate meningitis as the underlying cause rather than primary shock.
• Prepare the client for surgery: Surgery is not indicated in meningitis unless complications such as abscesses or obstructive hydrocephalus occur. The priority is medical management, neurological monitoring, and infection control.
• Administer gabapentin: Gabapentin is used for neuropathic pain and seizure disorders, and does not treat the infectious or inflammatory processes involved in meningitis. It does not address acute symptoms or underlying pathology.
• Administer sumatriptan: Sumatriptan is indicated for migraines and is contraindicated in conditions involving infection, fever, or neurologic compromise. Its vasoconstrictive effects could worsen cerebral perfusion in meningitis.
• Gait: Gait changes can occur in chronic neurologic disorders but are not a priority assessment in the acute management of meningitis. Immediate monitoring focuses on neurologic status and hemodynamic stability.
• Bowel sounds: Although documented as hyperactive on admission, bowel sounds do not reflect the severity or progression of meningitis. They do not guide treatment decisions for infectious or neurologic complications.
• Lactate level: Lactate monitoring is primarily associated with septic shock and poor tissue perfusion. While meningitis can progress to sepsis, the client’s current presentation prioritizes neurologic and temperature monitoring over lactate assessment.
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII?
A nurse is caring for a client who had a thoracentesis 2 hr ago. Which of the following findings should the nurse expect?
A nurse is caring for a client receiving total parenteral nutrition who weighs 160 lb. If the RDA of protein is 0.3 g/kg of body weight, how many grams of protein should the client receive daily? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
- Convert the client’s weight from pounds to kilograms
Weight (kg) = Weight (lb) ÷ 2.2
Weight (kg) = 160 ÷ 2.2
Weight (kg) = 72.73 kg
- Calculate the daily protein requirement
Protein Requirement (g) = Weight (kg) × RDA (g/kg)
Protein Requirement = 72.73 × 0.3
Protein Requirement = 21.82 g
- Round to the nearest whole number
= 22 g
A home health nurse is assessing a client who has COPD. Which of the following findings indicates the need for a referral for pulmonary rehabilitation?
A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take?
A nurse is planning to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse plan to take?
A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal?
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