Test bank medical surgical nursing concepts for

Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 362
d. Neck and shoulder tenderness
e. Nasal congestion
f. Exophthalmos
RESPONSE: A, B, E
Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal congestion, ptosis,
eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and
exophthalmos are not associated with cluster headaches.
DIF: Understanding/Comprehension REF: 861
KEY: Migraine| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should
the nurse assess? (Select all that apply.)
a. Intermittent rigidity
b. Lip smacking
c. Sudden loss of muscle tone
d. Brief jerking of the extremities
e. Picking at clothing
f. Patting of the hand on the leg
RESPONSE: B, E, F
Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at
clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the
extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.
DIF: Understanding/Comprehension REF: 862
KEY: Seizure| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal
protective equipment should the nurse wear? (Select all that apply.)
a. Particulate respirator
b. Isolation gown
c. Shoe covers
d. Surgical mask
e. Gloves
RESPONSE: D, E
Meningeal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers
should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions,
including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet
Precautions.
DIF: Applying/Application REF: 869
KEY: Meningitis| infection control| Trresponsemission-Based
Precautions MSC: Integrated Process: Nursing Process:
Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for
secondary seizures? (Select all that apply.)
a. A 26-year-old woman with a left temporal brain tumor
b. A 38-year-old male client in an alcohol withdrawal program
c. A 42-year-old football player with a traumatic brain injury
d. A 66-year-old female client with multiple sclerosis
e. A 72-year-old man with chronic obstructive pulmonary disease