Adult Health Exam # 3
What pre-procedure preparations should the nurse complete in a patient undergoing a lumbar puncture?
1. Obtain informed consent 2. Explain the procedure 3. Positioning required
The nurse is about to administer a contrast medium to the client undergoing diagnostic testing. Which question does the nurse first ask the client? A. "Are you taking ibuprofen daily?" B. "Are you in pain?" C. "Are you wearing any metal?" D. "Do you know what this test is for?"
A. "Are you taking ibuprofen daily?"
The nurse is teaching a client about the risk factors of restless legs syndrome. Which statement by the client indicates a correct understanding of the nurse's instruction? A. "Cigarettes and alcohol should be avoided." B. "I should exercise my legs before bedtime." C. "It is important to stay off my feet." D. "Over-the-counter drugs should not be taken."
A. "Cigarettes and alcohol should be avoided."
A client's spouse expresses concern that the client, who has Guillain-Barré syndrome, is becoming very depressed and will not leave the house. What is the nurse's best response? A. "Contact the Guillain-Barré Syndrome Foundation International for resources." B. "Try inviting several people over so the client won't have to go out." C. "Let your spouse stay alone. Your spouse will get used to it." D. "This behavior is normal."
A. "Contact the Guillain-Barré Syndrome Foundation International for resources."
The nursing instructor asks a nursing student to compare and contrast Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct? A. "Difficulty chewing may occur in both disorders." B. "Both are disorders of the autonomic nervous system." C. "Facial twitching occurs in both disorders." D. "Both disorders are caused by the herpes simplex virus, which inflames and irritates cranial nerve V."
A. "Difficulty chewing may occur in both disorders."
The spouse of the client with Alzheimer's disease is listening to the hospice nurse explaining the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." B. "Memantine (Namenda) is indicated for treatment of early symptoms of Alzheimer's disease. C. "Rivastigmine (Exelon) is used to treat depression." D. "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."
A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease."
The nurse's friend fears that his mother is getting old, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? A. "Have you taken her for a check-up?" B. "She has Alzheimer's disease." C. "That is a normal part of aging." D. "You should look into respite care."
A. "Have you taken her for a check-up?"
A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? A. "I can go home the day of the procedure." B. "I can go home 48 hours after the procedure." C. "I'll have a drain in place after the procedure." D. "I'll need to wear special stockings after the procedure."
A. "I can go home the day of the procedure."
A client with myasthenia gravis (MG) is receiving cholinesterase inhibitor drugs to improve muscle strength. The nurse is educating the family about this therapy. Which statement by a family member indicates a correct understanding of the nurse's instruction? A. "I should call 911 if a sudden increase in weakness occurs." B. "I should increase the dose if a sudden increase in weakness occurs." C. "The medication should be taken with a large meal." D. "The medication should be taken on an empty stomach."
A. "I should call 911 if a sudden increase in weakness occurs."
A client has been diagnosed with Huntington disease (HD). The nurse is teaching the client and her parents about the genetic aspects of the disease. Which statement made by the parents demonstrates a good understanding of the nurse's teaching? A. "If she has children, she'll pass the gene on to her kids." B. "She could only have gotten the disease from both of us." C. "Because she got the gene from her father, she'll live longer than others with HD." D. "More testing should definitely be done to see if she's really got the gene."
A. "If she has children, she'll pass the gene on to her kids."
A client with a spinal cord tumor and a poor prognosis has lost bladder control. The client asks the nurse whether the suggested surgery will be "worth it." What is the nurse's best response? A. "It should help return bladder control." B. "Let me call the surgeon so you can ask the rest of your questions." C. "What do you think?" D. "What does your family think?"
A. "It should help return bladder control."
A client is being evaluated for signs associated with myasthenic crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis? A. Abdominal cramps, blurred vision, facial muscle twitching B. Bowel and bladder incontinence, pallor, cyanosis C. Increased pulse, anoxia, decreased urine output D. Restlessness, increased salivation and tearing, dyspnea
A. Abdominal cramps, blurred vision, facial muscle twitching
The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? A. Absence B. Myoclonic C. Simple partial D. Tonic
A. Absence
A client newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the client's spouse? A. Administer medications promptly on schedule to maintain therapeutic drug levels. B. Complete activities of daily living for the client. C. Speak loudly for better understanding. D. Provide high-calorie, high-carbohydrate foods to maintain the client's weight.
A. Administer medications promptly on schedule to maintain therapeutic drug levels.
A client with trigeminal neuralgia is admitted for a percutaneous stereotactic rhizotomy in the morning. The client currently reports pain. What does the nurse do next? A. Administers pain medication as requested B. Ensures that the client has nothing by mouth (NPO) C. Ensures that the preoperative laboratory work is complete D. Performs a preoperative assessment
A. Administers pain medication as requested
A client with amyotrophic lateral sclerosis is degenerating rapidly and will soon need respiratory support. What does the nurse plan to review with this client? A. Advance directives B. How to use the ventilator C. Funeral plans D. Nutritional support
A. Advance directives
A client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What does the nurse do next? A. Allow the client to remain undisturbed. B. Assess the client's vital signs. C. Remove the cloth because it can harbor microorganisms. D. Turn on the lights for a neurologic assessment.
A. Allow the client to remain undisturbed.
The wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress? A. Arranges for respite care B. Provides positive reinforcement and support to the wife C. Restrains the client for a short time each day, to allow the wife to rest D. Teaches the client improved self-care
A. Arranges for respite care
A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? A. Assesses airway, breathing, and circulation B. Calls the provider C. Performs a neurologic check D. Assists the client to a sitting position
A. Assesses airway, breathing, and circulation
A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A. Assessing neurologic status at least every 2 to 4 hours B. Decreasing environmental stimuli C. Managing pain through drug and nondrug methods D. Strict monitoring of hourly intake and output
A. Assessing neurologic status at least every 2 to 4 hours
A client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care? A. Assigning a case manager B. Ensuring that all family questions are answered before discharge C. Providing a safe environment D. Referring the family to the Alzheimer's Association
A. Assigning a case manager
The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for treatment of intractable partial seizures. The nurse plans to contact the health care provider if the client has which condition? A. Bipolar disorder B. Diabetes mellitus C. Glaucoma D. Hypothyroidism
A. Bipolar disorder
A client has just returned from cerebral angiography. Which symptom does the client display that causes the nurse to act immediately? A. Bleeding B. Increased temperature C. Severe headache D. Urge to void
A. Bleeding
The nurse encourages a ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique? A. Blinking for "yes" or "no" B. Moving lips to speak C. Using sign language D. Using a laptop to write
A. Blinking for "yes" or "no"
In addition to frequent re-positioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury? A. Chair pad B. Thromboembolism-deterrent (TED) hose C. Trapeze D. Water bottle
A. Chair pad
A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse? A. Chest tightness B. Skin flushing C. Tingling feelings D. Warm sensation
A. Chest tightness
Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? A. Cloudy, turbid CSF B. Decreased white blood cells C. Decreased protein D. Increased glucose
A. Cloudy, turbid CSF
The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age? A. Decreased coordination B. Increased sleeping during the night C. Increased touch sensation D. Stability in pain perception
A. Decreased coordination
A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? A. Drowsiness B. Hirsutism C. Hypertension D. Tachycardia
A. Drowsiness
A client with Parkinson disease is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective? A. Involving the client and his wife in developing a plan of care B. Setting up visitations by a home health nurse C. Telling his wife what the client needs D. Writing up a detailed plan of care according to standards
A. Involving the client and his wife in developing a plan of care
A patient is admitted to the critical care unit with possible Guillain-Barré syndrome. Which symptom of neurologic impairment will require priority nursing interventions? Select all that apply. A. New adventitious breath sounds B. A respiratory rate of 12 C. Rapid, shallow breathing pattern D. A peripheral oxygen saturation (Spo2) of 90% E. New-onset nausea following a position change
A. New adventitious breath sounds C. Rapid, shallow breathing pattern D. A peripheral oxygen saturation (Spo2) of 90%
In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? A. Patent airway B. Indication of allergies C. Level of consciousness D. Loss of sensation
A. Patent airway
A client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? A. Potential for injury related to chronic confusion and physical deficits B. Risk for reduced mobility related to progression of disability C. Potential for skin breakdown related to immobility and/or impaired nutritional status D. Lack of social contact related to personality and behavior changes
A. Potential for injury related to chronic confusion and physical deficits
Which statement correctly illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)? A. The client's respiratory status and muscle function are affected by both diseases. B. Both diseases are autoimmune diseases with ocular symptoms. C. Both diseases exhibit exacerbations and remissions of their signs and symptoms. D. Demyelination of neurons is a cause of both diseases.
A. The client's respiratory status and muscle function are affected by both diseases.
The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority? A. Young adult whose Glasgow Coma Scale (GCS) score has changed from 15 to 10 B. Adult whose deep tendon reflexes have become hyperactive C. Middle-aged adult who displays plantar flexion when the bottom of the foot is stroked D. Older adult who consistently demonstrates decortication when stimulated
A. Young adult whose Glasgow Coma Scale (GCS) score has changed from 15 to 10
Which client diagnosed with neurologic injury is typically at highest risk for depression? A. Young man with a spinal cord injury B. Older man with a spinal cord injury C. Older man with a mild stroke D. Young woman with a mild stroke
A. Young man with a spinal cord injury
A client has received contrast medium. Which teaching does the nurse provide to avoid any neurologic health problems after the procedure? A. "Practice memory drills this afternoon." B. "Drink at least 1000 to 1500 mL of water today." C. "Avoid sunlight." D. "Rest in bed for 24 hours."
B. "Drink at least 1000 to 1500 mL of water today."
A client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching? A. "It is important to post my medicine schedule at home, so my family knows my schedule." B. "I can continue to take over-the-counter drugs." C. "An extra supply of medicine should be kept in my car." D. "Wearing a watch with an alarm will remind me to take my medicine."
B. "I can continue to take over-the-counter drugs."
The nurse is teaching a client newly diagnosed with migraines about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A. "I can still eat Chinese food." B. "I must not miss meals." C. "It is okay to drink a few wine coolers." D. "I need to use fake sugar in my coffee."
B. "I must not miss meals."
A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? A. "Sumatriptan should be taken as a last resort." B. "I must report any chest pain right away." C. "Birth control is not needed while taking sumatriptan." D. "St. John's wort can also be taken to help my symptoms."
B. "I must report any chest pain right away."
A decrease of ____ or more points in the Glasgow Coma Scale total is clinically significant and should be reported to the health care provider immediately. A. 1 B. 2 C. 3 D. 4
B. 2
The nurse has just received report on a group of clients. Which client does the nurse assess first? A. Young adult who was in a car accident and has a Glasgow Coma Scale score of 13 B. Adult who had a cerebral arteriogram and has a cool, pale right leg C. Middle-aged adult who has a headache after undergoing a lumbar puncture D. Older adult who has expressive aphasia after a left-sided stroke
B. Adult who had a cerebral arteriogram and has a cool, pale right leg
A client returns to the neuromedicine floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? A. Administer pain medication. B. Assess airway and breathing. C. Assist with ambulation. D. Check the client's ability to void.
B. Assess airway and breathing.
A client has returned to the unit after peripheral nerve repair surgery following a traumatic injury to the right hand. Which nursing intervention is done first in the postoperative period? A. Applying lanolin to dry skin B. Assessing skin for tightness, warmth, and color C. Loosening the splint if it is too tight D. Teaching the client how to avoid temperature extremes
B. Assessing skin for tightness, warmth, and color
The nurse is caring for a client with advanced Alzheimer's disease. Which communication technique is best to use with this client? A. Providing the client with several options to choose from B. Assuming that the client is not totally confused C. Waiting for the client to express a need D. Writing down instructions for the client
B. Assuming that the client is not totally confused
Which task does the nurse plan to delegate to the nursing assistant caring for a group of clients in the neurosurgical unit? A. Prepare a client who is going to radiology for a cerebral arteriogram B. Attend to the care needs of a client who has had a transcranial Doppler study C. Assist the health care provider in performing a lumbar puncture on a confused client D. Educate a client about what to expect during an electroencephalogram (EEG)
B. Attend to the care needs of a client who has had a transcranial Doppler study
The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the health care provider will request which medication to aid in the diagnosis of MG? A. Atropine B. Edrophonium chloride (Tensilon) C. Methylprednisolone (Solu-Medrol) D. Morphine sulfate
B. Edrophonium chloride (Tensilon)
The nurse admits a client with suspected Eaton-Lambert syndrome. The nurse anticipates that the health care provider will request which test to confirm the diagnosis? A. Doppler study B. Electromyography (EMG) C. Magnetic resonance imaging (MRI) D. Tensilon test
B. Electromyography (EMG)
A client has Guillain-Barré syndrome. Which interdisciplinary health care team members does the nurse plan to collaborate with to help prevent pressure ulcers related to immobility in this client? (Select all that apply.) A. Certified hospital chaplain B. Family members C. Dietitian D. Occupational therapist (OT) E. Social worker
B. Family members C. Dietitian D. Occupational therapist (OT)
Which is the most effective way for a college student to minimize the risk for bacterial meningitis? A. Avoid large crowds. B. Get the meningococcal vaccine. C. Take a daily vitamin. D. Take prophylactic antibiotics.
B. Get the meningococcal vaccine.
The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? (Select all that apply.) A. Alopecia B. Headaches C. Dizziness D. Diplopia E. Increased blood glucose
B. Headaches C. Dizziness D. Diplopia
A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? (Select all that apply.) A. Bite block at the bedside B. Intravenous access C. Continuous sedation D. Suction equipment at the bedside E. Siderails up
B. Intravenous access D. Suction equipment at the bedside E. Siderails up
During a patient's neurologic assessment, the nurse finds that he is arousable after light touch combined with a loud voice. How does the nurse document this patient's level of consciousness? A. Stuporous B. Lethargic C. Comatose D. Drowsy
B. Lethargic
The nurse is caring for a client who is scheduled to have a brain biopsy. The nurse anticipates that the health care provider will request which test before the brain biopsy is performed? A. Lumbar puncture (LP) B. Magnetic resonance imaging (MRI) C. Skull x-ray D. Transcranial Doppler ultrasonography (TCD)
B. Magnetic resonance imaging (MRI)
The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will prescribe which medication? A. Dopamine hydrochloride (Inotropin) B. Nifedipine (Procardia) C. Methylprednisolone (Solu-Medrol) D. Ziconotide (Prialt)
B. Nifedipine (Procardia)
The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? A. Neck pain is at a level 7 on a 0-to-10 scale. B. The client is reporting difficulty swallowing secretions. C. The client has numbness and tingling bilaterally down the arms. D. Serosanguineous fluid oozes onto the neck dressing.
B. The client is reporting difficulty swallowing secretions.
The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)
B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes
The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? (Select all that apply.) A. "Standing for long periods of time will help to prevent low back pain." B. "Keep weight within 50% of ideal body weight." C. "Begin a regular exercise program." D. "When lifting something, the back should be straight and the knees bent." E. "Do not wear high-heeled shoes."
C. "Begin a regular exercise program." D. "When lifting something, the back should be straight and the knees bent." E. "Do not wear high-heeled shoes."
The daughter of a client who has had a stroke asks the nurse for additional resources. What is the nurse's best response? A. "Call hospice." B. "Check the Internet." C. "Go to the National Stroke Association website." D. "The charge nurse at the desk has all of the information."
C. "Go to the National Stroke Association website."
The nurse is teaching a client and her husband about sexuality issues after a spinal cord injury. Which comment by the client indicates a correct understanding of the nurse's instruction? A. "I can no longer become pregnant." B. "If I become pregnant, I cannot give birth." C. "I may still be able to get pregnant." D. "My children will be paralyzed."
C. "I may still be able to get pregnant."
The nursing instructor asks the student nurse caring for a client with Alzheimer's disease who has been prescribed donepezil (Aricept) how the drug works. Which response by the nursing student best explains the action of donepezil? A. "The reuptake of serotonin is blocked." B. "Donepezil prevents the increase in the protein beta amyloid." C. "It delays the destruction of acetylcholine by acetylcholinesterase." D. "Dopamine levels are increased."
C. "It delays the destruction of acetylcholine by acetylcholinesterase."
The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? A. "Can't you take care of your spouse?" B. "Establishing goals and a daily plan can help." C. "Make sure you take some time off and take care of yourself too." D. "That's not a very nice thing to say."
C. "Make sure you take some time off and take care of yourself too."
The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? A. "I will die early." B. "I will have gradual deterioration with no healthy times." C. "Parts of my nervous system have plaques." D. "This was caused by getting too many x-rays as a child."
C. "Parts of my nervous system have plaques."
Which client does the neurologic unit charge nurse assign to a registered nurse who has floated from the labor/delivery unit for the shift? A. Older adult client who was just admitted with a stroke and needs an admission assessment B. Young adult client who has had a lumbar puncture and reports, "Light hurts my eyes." C. Adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes D. Middle-aged client who has a possible brain tumor and has questions about the scheduled magnetic resonance imaging
C. Adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes
A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? A. Administer phenytoin (Dilantin). B. Draw the client's blood. C. Assess the need for additional support. D. Start an intravenous (IV) line.
C. Assess the need for additional support.
A client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A. Stroke B. Tension headache C. Classic migraine D. Cluster headache
C. Classic migraine
The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? A. Apple juice B. Grape juice C. Grapefruit juice D. Milk
C. Grapefruit juice
The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving intravenous immunoglobulin (IVIG). Which assessment finding warrants immediate evaluation? A. Chills B. Generalized malaise C. Headache with stiff neck D. Temperature of 99° F (37° C)
C. Headache with stiff neck
A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? A. Check for fecal impaction. B. Insert a straight catheter. C. Help the client sit up. D. Loosen the client's clothing.
C. Help the client sit up.
The nurse has just received change-of-shift report about a group of clients on the neurosurgical unit. Which client does the nurse attend to first? A. Young adult client involved in a motor vehicle crash (MVC) who is yelling obscenities at the nursing staff B. Adult postoperative left craniotomy client whose hand grips are weaker on the right C. Middle-aged adult client who had a cerebral aneurysm clipping and is increasingly stuporous D. Older adult client who had a carotid endarterectomy and is unable to state the day of the week
C. Middle-aged adult client who had a cerebral aneurysm clipping and is increasingly stuporous
A client arrives in the emergency department with new-onset ptosis, diplopia, and dysphagia. The nurse anticipates that the client will be tested for which neurologic disease? A. Bell's palsy B. Guillain-Barré syndrome (GBS) C. Myasthenia gravis (MG) D. Trigeminal neuralgia
C. Myasthenia gravis (MG)
Which information is most important for the nurse to communicate to the health care provider about a client who is scheduled for cerebral angiography? A. Allergy to penicillin B. History of bacterial meningitis C. Poor skin turgor and dry mucous membranes D. The client's dose of metformin (Glucophage) held today
C. Poor skin turgor and dry mucous membranes
A client with myasthenia gravis is admitted with generalized fatigue, a weak voice, and dysphagia. Which client problem has the highest priority? A. Inability to tolerate everyday activities related to severe fatigue B. Inability to communicate verbally related to vocal weakness C. Potential for aspiration related to difficulty with swallowing D. Inability to care for self related to muscle weakness
C. Potential for aspiration related to difficulty with swallowing
A client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention does the nurse perform first? A. Calls the Rapid Response Team to intubate B. Instructs the client on how to cough effectively C. Raises the head of the bed to 45 degrees D. Suctions the client
C. Raises the head of the bed to 45 degrees
Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? A. Frequent ambulation B. Encouraging nutrition C. Regular turning and re-positioning D. Special pressure-relief devices
C. Regular turning and re-positioning
A client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? A. Alzheimer's Wandering Association B. National Alzheimer's Group C. Safe Return Program D. Lost Family Members Tracking Association
C. Safe Return Program
In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? A. Gait B. Mobility C. Sensation D. Strength
C. Sensation
The nurse is caring for a client in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action? A. Electrocardiographic monitoring shows a sinus bradycardia at a rate of 50 beats/min. B. The client demonstrates flaccid paralysis below the level of injury. C. The client's chest moves very little with each respiration. D. After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg.
C. The client's chest moves very little with each respiration.
The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating. The nurse suspects that which cranial nerve has been affected? A. Abducens B. Facial C. Trigeminal D. Trochlear
C. Trigeminal
Which cranial nerve allows a person to feel a light breeze on the face? A. I (olfactory) B. III (oculomotor) C. V (trigeminal) D. VII (facial)
C. V (trigeminal)
The nurse is instructing a client for whom a positron emission tomography (PET) scan has been requested. Which statement indicates to the nurse that the client understands the instructions? A. "It's okay to have a cup of coffee before the test." B. "Because I am diabetic, I will take my insulin just before the test." C. "I can continue to smoke cigarettes up to 4 hours before the test." D. "I will drink plenty of fluids after the test."
D. "I will drink plenty of fluids after the test."
The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions? A. "Riluzole should be taken with food." B. "I plan to take riluzole once daily." C. "I will call the health care provider if my pulse goes below 50." D. "I will need frequent checks of my liver enzymes."
D. "I will need frequent checks of my liver enzymes."
The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? A. "Begin driving 1 week after discharge." B. "Avoid using a pillow under the head while sleeping." C. "Swimming is recommended to keep active." D. "Keep straws available for drinking fluids."
D. "Keep straws available for drinking fluids."
A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? A. "Next time you eat, try lifting your chin when you swallow." B. "Let's advance your diet to solid food." C. "Let's see if the dietitian can help." D. "Let's see if the speech-language pathologist can help."
D. "Let's see if the speech-language pathologist can help."
A client with new-onset Bell's palsy is being discharged. Which statement made by the client demonstrates a need for further discharge teaching by the nurse? A. "I'll need artificial tears at least four times a day." B. "I will eat a soft diet." C. "My eye must be taped or patched at bedtime." D. "Narcotics will be needed for pain relief."
D. "Narcotics will be needed for pain relief."
A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? A. "Every injury is different, and it is too soon to have any real answers right now." B. "Only time will tell." C. "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." D. "Please request a meeting with the health care provider."
D. "Please request a meeting with the health care provider."
A client has undergone single-photon emission computed tomography (SPECT). Which instruction does the nurse give the client? A. "Continue to use the ice pack." B. "Call me if you have any itching." C. "Keep the head of the bed flat." D. "Return to your usual activity."
D. "Return to your usual activity."
The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment finding is normal? A. Decerebrate posturing B. Increased lethargy C. Minimal response to stimulation D. Constriction of pupils
D. Constriction of pupils
The nurse prepares to assess a client with diabetes mellitus for sensory loss. Which equipment does the nurse use to perform this assessment? A. Glucometer B. Hammer C. Nothing; the client is asked to walk D. Cotton-tipped applicator
D. Cotton-tipped applicator
A client has returned to the unit after a thymectomy and is extubated. The client begins to report chest pain. What does the nurse do next? A. Calls the Rapid Response Team for immediate intubation B. Gives sublingual nitroglycerin (Nitrostat) C. Increases the intravenous (IV) rate D. Informs the surgeon immediately
D. Informs the surgeon immediately
A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? A. Getting the client up in a chair B. Keeping the client in the Trendelenburg position C. Lifting the client in unison with other health care personnel D. Log rolling the client
D. Log rolling the client
A client has Parkinson disease (PD). Which nursing intervention best protects the client from injury? A. Discouraging the client from activity B. Encouraging the client to watch the feet when walking C. Suggesting that the client obtain assistance in performing activities of daily living (ADLs) D. Monitoring the client's sleep patterns
D. Monitoring the client's sleep patterns
A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? A. Hospital library B. Internet C. Provider's office D. National Spinal Cord Injury Association
D. National Spinal Cord Injury Association
A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? A. Auscultating bowel sounds every 2 hours B. Beginning a bladder retraining program C. Monitoring nutritional status D. Positioning the client to maximize ventilation potential
D. Positioning the client to maximize ventilation potential
The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure. B. Forces a tongue blade in the mouth. C. Restrains the client. D. Positions the client on the side.
D. Positions the client on the side.
The nurse is reviewing the medication history of a client diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase (ChE) inhibitor. The nurse contacts the health care provider if the client is taking which medication? A. Acetaminophen (Tylenol) B. Furosemide (Lasix) C. Ibuprofen (Motrin) D. Procainamide (Pronestyl)
D. Procainamide (Pronestyl)
To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the health care team is a nursing priority? A. Nutritional therapy B. Occupational therapy C. Physical therapy D. Respiratory therapy
D. Respiratory therapy
The results of a client's lumbar puncture indicate that the client's protein level is 150 mg/dL. The nurse suspects that the client may have which condition? A. Guillain-Barré syndrome B. Meningismus C. Paraventricular tumor D. Viral infection
D. Viral infection
Changes in _____________ are the earliest signs of changes in neurologic status
cognition
In older adults, a decrease in _____________ ____________ is a key early sign of an infectious process.
mental status
