Adult Health Exam 3

A client is prone to experiencing autonomic dysreflexia. Which of the following measures implemented by the nurse would minimize the risk of recurrence of autonomic dysreflexia? A. Strict adherence to a bowel retraining program B. Keeping the linen under the client free of wrinkles C. Preventing unnecessary pressure on the lower limbs D. Limiting bladder catheterization to once every 12 hours

A. Strict adherence to a bowel retraining program

The nurse is caring for a client newly diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? A. Vision changes B. Absent deep tendon reflexes C. Tremors at rest D. Flaccid muscles

A. Vision changes

The nurse is caring for the client with increased ICP. The nurse would note which of the following trends in vital signs if the ICP is rising? A. Increasing temperature, increasing respirations, decreasing blood pressure B. Decreasing respirations, decreasing pulse, increasing blood pressure C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

B. Decreasing respirations, decreasing pulse, increasing blood pressure

The nurse is teaching the client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: A. Take a hot bath B. Rest in an air-conditioned room C. Increase the dose of muscle relaxants D. Avoid naps during the day

B. Rest in an air-conditioned room

A nurse is reviewing the record of a client with increased ICP and notes that the client has exhibited signs of decerebrate posturing. On assessment of the client, the nurse would expect to note which of the following if this type of posturing was present? A. Abnormal flexion of the upper extremities and extension of the lower extremities B. Rigid extension and pronation of the arms and legs C. Rigid pronation of all extremities D. Flaccid paralysis of all extremities

B. Rigid extension and pronation of the arms and legs

A client who is paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? A. The client leaves the side rails down B. The client performs regular skin assessments C. The client repositions themselves only when reminded to do so D. The client hangs the left arm over the side of the wheelchair

B. The client performs regular skin assessments

During the acute stage of meningitis, a child is restless and irritable. Which of the following would be most important to institute? A. Limiting conversation with the child B. Allowing the child to play in the bathtub C. Keeping extraneous noise to a minimum D. Performing treatments quickly

C. Keeping extraneous noise to a minimum

You as the RN are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to the LPN? A. Admission assessment of the new client B. Place a padded tongue blade at the bedside C. Set up oxygen and suction equipment D. Prime the Keppra drip and load it into the pump

C. Set up oxygen and suction equipment

The nurse is caring for a client who underwent surgery of the lumbar spine two days ago. Which of the following findings should the nurse consider abnormal? A. More back pain than the first postoperative day B. Paresthesia in the dermatomes near the wounds C. Urine retention or incontinence D. Temperature of 99.2 degrees F

C. Urine retention or incontinence

A male client is having tonic-clonic seizures. What should the nurse do first? A. Elevate the head of the bed B. Restrain the client's arms and legs C. Place a tongue blade in the client's mouth D. Take measures to prevent injury E. Panic

D. Take measures to prevent injury