Exam 2

16. A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a.Assist with active range of motion (ROM). b.Observe for agitation and paranoia. c.Give muscle relaxants as needed to reduce spasms. d.Use simple words and phrases to explain procedures.

ANS: A ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patients ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

33. After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as like a band around my head c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinsons disease who has developed cogwheel rigidity of the arms

ANS: A Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should also be assessed, but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.

The nurse reviews laboratory data for a client who has Guillain-Barré syndrome (GBS). Which result does the nurse correlate with this disease process? a. Increased cerebrospinal fluid (CSF) protein level b. Decreased serum protein electrophoresis results c. Increased antinuclear antibodies d. Decreased immune globulin G (IgG) levels

ANS: A A lumbar puncture is performed to evaluate the CSF. An increased CSF protein level without increased cell count is a distinguishing feature of GBS. The other results are not associated with GBS.

A client who has myasthenia gravis is receiving atropine for a cholinergic crisis. Which intervention does the nurse implement for this client? a. Suction the client to remove secretions. b. Turn and reposition the client every 2 hours. c. Measure urinary output every 30 minutes. d. Administer prescribed anticholinergic drugs as needed.

ANS: A Atropine can cause thickening of secretions and formation of mucous plugs. The client is maintained on a ventilator during the crisis. Measures to remove secretions to prevent the buildup of secretions and the possibility of pneumonia are most important. The other interventions do not relate to the administration of atropine.

The nurse teaches a client who has autonomic dysfunction about injury prevention. Which statement indicates that the client correctly understands the teaching? a. "I will change positions slowly." b. "I will avoid wearing cotton socks." c. "I will use an electric razor." d. "I will use a heating pad on my feet."

ANS: A Autonomic dysfunction causes orthostatic hypotension. The client should change positions slowly to prevent orthostatic hypotension. Autonomic dysfunction can cause peripheral polyneuropathy, so the client should be taught to wear socks and shoes at all times and not to use a heating pad. The disorder does not cause bleeding; therefore the client can use any type of razor.

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. "Participate in an exercise program to strengthen muscles." b. "Purchase a mattress that allows you to adjust the firmness." c. "Wear flat instead of high-heeled shoes to work each day." d. "Keep your weight within 20% of your ideal body weight."

ANS: A Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.

An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best? a. Assess the client's oxygen saturation. b. Check the medication list for interactions. c. Place the client on a bed alarm. d. Put the client on safety precautions.

ANS: A In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation. The other actions are appropriate, but only after this assessment occurs.

The nurse is assessing a client with trigeminal neuralgia. Which clinical manifestation does the nurse expect to observe? a. Excruciating pain b. Decreased mobility c. Controllable facial twitching d. Increased talkativeness

ANS: A Signs of trigeminal neuralgia are excruciating pain and uncontrollable facial twitching which causes the client to avoid talking, smiling, eating, or attending to hygienic needs. Sensory and mobility deficits are not associated with trigeminal neuralgia.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

ANS: A, C, D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the client's oral fluid intake. e. Assess the chest and back for skin breakdown.

ANS: A, B, E A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.

The nurse caring for a client with Guillain-Barré syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.) a. Ask occupational therapy to help the client with activities of daily living. b. Consult with the provider about a physical therapy consult. c. Provide the client with information on support groups. d. Refer the client to a medical social worker or chaplain. e. Work with speech therapy to design a high-protein diet.

ANS: A, B, E Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy. While support groups, social work, or chaplain referrals may be needed, they do not help with mobility.

A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching the client? (Select all that apply.) a. Acyclovir b. Carbamazepine c. Famciclovir d. Prednisone e. Valacyclovir

ANS: A, C, D, E Possible pharmacologic treatment for Bell's palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bell's palsy.

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

ANS: A, C, D, F Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

The nurse is preparing to send a cerebrospinal fluid sample to the laboratory. Which actions does the nurse implement during this procedure? (Select all that apply.) a. Use Standard Precautions. b. Wear sterile gloves when handling the specimen. c. Place the specimen on ice. d. Send the specimen in a sealed bag displaying a biohazard symbol. e. Confirm the specimen label with the client's identification band.

ANS: A, D, E The Standard Precautions approach is based on the premise that a medical history and a physical examination cannot reliably identify all those infected by pathogens. Consequently, health care workers should consider all human blood and body fluids as potentially infectious and must use appropriate protective measures to prevent possible exposure. Specimens should be labeled appropriately and transported in a sealed bag displaying the biohazard symbol. The nurse should use Standard Precautions when handling the specimen. The nurse should also confirm the identification of the client and the specimen. The nurse does not need sterile gloves, and the specimen should not be iced.

Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine . An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a.Auscultate the patients bowel sounds. b.Notify the patients health care provider. c.Administer the prescribed PRN antiemetic drug. d.Give the scheduled dose of prednisone.

ANS: B The patients history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

The nurse is caring for a client who has undergone peripheral nerve repair. Which priority assessment does the nurse perform postoperatively? a. Evaluate extremity mobility. b. Assess the skin surrounding the cast. c. Test distal extremities for sensation. d. Auscultate bowel sounds.

ANS: B The nurse assesses the skin surrounding the cast hourly for tightness, warmth, and color. If the cast is too tight, the nurse notifies the provider immediately. The other assessments should be completed after a circulatory assessment.

An older adult client is hospitalized with Guillain-Barré syndrome. The client is given amitriptyline . After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.) a. Administering the medication as ordered b. Advising the client to have help getting up c. Consulting the provider about the drug d. Cutting the dose of the drug in half e. Placing the client on safety precautions

ANS: B, C, E Amitriptyline is a tricyclic antidepressant and is considered inappropriate for use in older clients due to concerns of anticholinergic effects, confusion, and safety risks. The nurse should tell the client to have help getting up, place the client on safety precautions, and consult the provider. Since this drug is not appropriate for older clients, cutting the dose in half is not warranted.

A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the client's gag reflex b. Cutting foods up into small bites c. Monitoring prealbumin levels d. Thickening liquids prior to drinking e. Weighing the client daily

ANS: B, D Cutting food up into smaller bites makes it easier for the client to chew and swallow. Thickened liquids help prevent aspiration. The UAP can weigh the client, but this does not help improve nutrition. The nurse assesses the gag reflex and monitors laboratory values.

A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that an informed consent has been obtained before the test or procedure? a. Sensation measurement via the pinprick method b. Computed tomography of the cranial vault c. Lumbar puncture for cerebrospinal fluid sampling d. Venipuncture for autoantibody analysis

ANS: C A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive and do not require an informed consent.

A client with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem? a. Anxiety b. Low fluid volume c. Inadequate airway d. Potential for skin breakdown

ANS: C Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.

The nurse is assessing a client who reports severe knee pain after a fall. Which question does the nurse ask to determine the radiation of the pain? a. "What makes the pain better or worse?" b. "Are you able to bear any weight on the knee at all?" c. "Does the pain move to another area from your knee?" d. "How would you rate the pain on a scale of 1 to 10?"

ANS: C To determine radiation of the pain, the nurse asks the client if the pain moves to another area from the knee. The other questions address the amount, functional impact, and alleviating or aggravating factors of the pain.

The nurse teaches a client who has Guillain-Barré syndrome (GBS) about pain management. Which statement indicates that the client correctly understands the teaching? a. "I can use the button on the pump as often as I want to get more pain medication." b. "Aspirin will provide the best relief from my pain associated with this disease." c. "A combination of morphine and distraction helps bring me relief right now." d. "I should not have any pain as a result of impaired motor and sensory neurons."

ANS: C Typical pain from GBS often is not relieved by medication other than opiates. Distraction, repositioning, massage, heat, cold, and guided imagery may enhance the opiate effects. Patient-controlled analgesia (PCA) pumps should be set with appropriate doses and limits.

A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client? a. Giving antibiotics prior to treatments b. Monitoring the client's vital signs c. Performing appropriate hand hygiene d. Placing the client in protective isolation

ANS: C . Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.

23. The nurse is planning to bathe a client diagnosed with meningococcal meningitis. In addition to gloves, what personal protective equipment does the nurse use? a.Particulate respirator b.Isolation gown c.Shoe covers d.Surgical mask

ANS: D Meningeal meningitis is spread via saliva and droplets. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first? a. Sleepy but arouses to voice b. Dry and cracked oral mucosa c. Pain present in lower back d. Bladder palpated above pubis

ANS: D A distended bladder may indicate damage to the sacral spinal nerves. The other findings require the nurse to provide care but are not the priority or a complication of the procedure.

The nurse learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse should understand that this causes what? a. Delayed afferent nerve impulses b. Paralysis of affected muscles c. Paresthesia in upper extremities d. Slowed nerve impulse transmission

ANS: D Demyelination leads to slowed nerve impulse transmission. The other options are not correct.

A client with myasthenia gravis is preparing for discharge. Which instructions does the nurse include when educating the client's family members or caregiver? a. Technique for therapeutic massage to the lower extremities b. Administration of morphine sulfate via an IV pump c. Instructions for preparing thin, puréed foods d. Cardiopulmonary resuscitation (CPR)

ANS: D Respiratory compromise is a common occurrence with myasthenia gravis. The client's family members are encouraged to learn CPR and to have resuscitation equipment available in the home. The other interventions are not a priority.

The nurse is assessing laboratory results for a client with myasthenia gravis (MG). Which results does the nurse correlate with this disease process? a. Elevated serum calcium level b. Decreased thyroid hormone level c. Decreased complete blood count d. Elevated acetylcholine receptor antibody levels

ANS: D Testing for acetylcholine receptor (AChR) antibodies is important because 80% to 90% of clients with the disease have elevated AChR antibody levels. The other laboratory results are not associated with myasthenia gravis.

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

NS: 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.

8. A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a.MS symptoms may be worse after the pregnancy. b.Women with MS frequently have premature labor. c.MS is associated with an increased risk for congenital defects. d. Symptoms of MS are likely to become worse during pregnancy.

ANS: A During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.

A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best? a. Ask the client to explain his feelings related to this disorder. b. Explain how dental hygiene is related to overall health. c. Refer the client to a medical social worker for assessment. d. Tell the client that he will become malnourished in time.

ANS: A Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.

A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important? a. Avoid large crowds and people who are ill. b. Check blood sugars four times a day. c. Use two forms of contraception. d. Wear properly fitting socks and shoes.

ANS: A Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. Wearing well-fitting shoes would be important to avoid injury, but not just because the client takes corticosteroids.

A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best? a. "MG is an autoimmune problem in which nerves do not cause muscles to contract." b. "MG is an inherited destruction of peripheral nerve endings and junctions." c. "MG consists of trauma-induced paralysis of specific cranial nerves." d. "MG is a viral infection of the dorsal root of sensory nerve fibers."

ANS: A MG is an autoimmune disorder in which nerve fibers are damaged and their impulses do not lead to muscle contraction. MG is not an inherited or viral disorder and does not paralyze specific cranial nerves.

9. A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask? a. Do you live in a crowded residence? b. When was your last tetanus vaccination? c. Have you had any viral infections recently? d. Have you traveled out of the country in the last month?

ANS: A Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information. The nurse should ask about travel to specific countries in which the disease is common, for example, sub-Saharan Africa.

The nurse is caring for a client with prostate cancer. Which laboratory finding indicates to the nurse that the cancer has metastasized to the bone? a. Serum calcium, 21.6 mg/dL b. Creatine kinase, 55 U/mL c. Alkaline phosphatase, 45 IU/mL d. Lactate dehydrogenase, 120 U/L

ANS: A Metastasis of tumor to bone results in release of calcium into the bloodstream, causing an elevation of the serum calcium level (normal range, 9 to 10.5 mg/dL). The other laboratory values are within normal limits and do not indicate metastasis to the bone.

4. The nurse advises a patient with myasthenia gravis (MG) to a.perform physically demanding activities early in the day. b.anticipate the need for weekly plasmapheresis treatments. c.do frequent weight-bearing exercise to prevent muscle atrophy. d.protect the extremities from injury due to poor sensory perception.

ANS: A Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled, but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used.

A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care? a. "I can scratch with a coat hanger." b. "I should feel my fingers for warmth." c. "I will keep the cast clean and dry." d. "I will return to have the cast removed."

ANS: A Nothing should be placed under the cast to use for scratching. The other statements show good indication that the client has understood the discharge instructions.

After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."

ANS: A Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowler's position to prevent aspiration.

A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders

ANS: A Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.

The nurse instructs a client who has myasthenia gravis to take prescribed medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase drugs. The client asks why the timing of meals is so important. Which is the nurse's best response? a. "This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke." b. "This timing prevents your blood sugar level from dropping too low and causing you to be at risk for falling." c. "These drugs are very irritating to your stomach and could cause ulcers if taken too long before meals." d. "These drugs cause nausea and vomiting. By waiting a while after you take the medication, you are less likely to vomit."

ANS: A Skeletal muscle weakness extends to the ability to chew and swallow. Clients who have myasthenia gravis are at risk for aspiration during meals. Timing the medication so that most of the meal is eaten when the drugs have produced their peak effect enables the client to chew and swallow more easily. The medication has no effect on blood glucose levels, ulcers, or nausea.

A client who has myasthenia gravis is recovering after a thymectomy. Which complication does the nurse monitor for in this client? a. Sudden onset of shortness of breath b. Swelling of the lower extremities c. Lower abdominal tenderness d. Decreased urinary output

ANS: A The complication to be alert for is pneumothorax or hemothorax. The nurse monitors the client for chest pain, sudden onset of shortness of breath, diminished chest wall expansion, decreased breath sounds, restlessness, and changes in vital signs. The other symptoms are not likely to occur or are not related to removal of the thymus.

The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? a. Inability to perform the six cardinal positions of gaze b. Lateralization to the affected side during the Weber test c. Absent deep tendon reflexes d. Impaired stereognosis

ANS: A The most common assessment finding in more than 90% of clients with myasthenia gravis is involvement of the extraocular muscles. The nurse observes for inability or difficulty with tests of extraocular function, such as the cardinal positions of gaze. Ptosis and incomplete eye closure also may be observed. Altered hearing and absent reflexes are not common in myasthenia gravis.

A client with myasthenia gravis is prescribed pyridostigmine What teaching should the nurse plan regarding this medication? (Select all that apply.) a. "Do not eat a full meal for 45 minutes after taking the drug." b. "Seek immediate care if you develop trouble swallowing." c. "Take this drug on an empty stomach for best absorption." d. "The dose may change frequently depending on symptoms." e. "Your urine may turn a reddish-orange color while on this drug."

ANS: A, B, D Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the client's manifestations. Taking the drug on an empty stomach is not related although the client needs to eat within 45 to 60 minutes afterwards. The client's urine will not turn reddish-orange while on this drug.

After teaching a client with a spinal cord tumor, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "Even though turning hurts, I will remind you to turn me every 2 hours." b. "Radiation therapy can shrink the tumor but also can cause more problems." c. "Surgery will be scheduled to remove the tumor and reverse my symptoms." d. "I put my affairs in order because this type of cancer is almost always fatal." e. "My family is moving my bedroom downstairs for when I am discharged home."

ANS: A, B, E Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal. Radiation therapy is often used to shrink spinal tumors but can cause progressive spinal cord degeneration and neurologic deficits. The client should be turned every 2 hours to prevent skin breakdown and arrangements should be made at home so that the client can complete activities of daily living without needing to go up and down stairs.

A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.) a. Sodium level b. Liver enzymes c. Clotting factors d. Cardiac enzymes e. Creatinine level

ANS: A, C Inflammation associated with meningitis can stimulate the hypothalamus and result in excessive production of antidiuretic hormone. The nurse should monitor sodium levels for early identification of syndrome of inappropriate antidiuretic hormone. A systemic inflammatory response (SIR) can also occur with meningitis. A SIR can result in a coagulopathy that leads to disseminated intravascular coagulation. The nurse should monitor clotting factors to identify this complication. The other laboratory values are not specific to complications of meningitis.

A client has just undergone surgery for peripheral nerve trauma. Which interventions does the nurse include in the client's plan of care? (Select all that apply.) a. Immobilization of the affected area with a splint b. Rotation of cold and heat therapy c. Occupational therapy d. Skin care, including hygiene and ointments e. High-fat, low-protein diet

ANS: A, C, D Care for the client with peripheral nerve trauma includes immobilization before and after surgery, and skin care to prevent skin breakdown and promote healing. The client may likely require physical or occupations therapy during the recovery process. The client will have decreased sensation, so cold and heat therapy should not be used. The client will require a diet high in protein to promote healing

3. A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells

ANS: A, C, D In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

11. Which action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder? a.Decrease the patients evening fluid intake. b.Teach the patient how to use the Cred method. c.Suggest the use of adult incontinence briefs for nighttime only. d.Assist the patient to the commode every 2 hours during the day.

ANS: B The Cred method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

7. When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should a.assess for the presence of chest pain. b.inquire about urinary tract problems. c.inspect the skin for rashes or discoloration. d.ask the patient about any increase in libido.

ANS: B Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

A nurse assesses the health history of a client who is prescribed ziconotide for chronic back pain. Which assessment question should the nurse ask? a. "Are you taking a nonsteroidal anti-inflammatory drug?" b. "Do you have a mental health disorder?" c. "Are you able to swallow medications?" d. "Do you smoke cigarettes or any illegal drugs?"

ANS: B Clients who have a mental health or behavioral health problem should not take ziconotide. The other questions do not identify a contraindication for this medication.

A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions? a. "Only lift items that are 10 pounds or less." b. "Wear your brace whenever you are out of bed." c. "You must remain in bed for 3 weeks after surgery." d. "You are prescribed medications to prevent rejection."

ANS: B Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.

The intensive care nurse is caring for a client who has Guillain-Barré syndrome. The nurse notes that the client's vital capacity has declined to 12 mL/kg, and the client is having difficulty clearing secretions. Which is the nurse's priority action? a. Place the client in a high Fowler's position. b. Prepare the client for elective intubation. c. Administer oxygen via a nasal cannula. d. Auscultate for breath sounds.

ANS: B Deterioration in vital capacity to less than 15 mL/kg and an inability to clear secretions are indications for elective intubation. The other interventions may assist with breathing and oxygenation but would not reverse the deterioration in vital capacity or help clear secretions.

The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome? a. Nerve impulses are not transmitted to skeletal muscle. b. The immune system destroys the myelin sheath. c. The distal nerves degenerate and retract. d. Antibodies to acetylcholine receptor sites develop.

ANS: B In Guillain-Barré syndrome, the immune system destroys the myelin sheath, causing segmental demyelination. Nerve impulses are transmitted more slowly but remain in place. Antibodies are not developed. The nerves do not degenerate and retract.

The nurse is assessing a client who had a dissection of all branches of the right trigeminal nerve. When asked to wrinkle his forehead, the client wrinkles only the left side. Which is the nurse's best action? a. Place the client in high Fowler's position. b. Document the finding. c. Assess the corneal reflex. d. Notify the health care provider.

ANS: B Loss of motor and sensory function after complete trigeminal nerve dissection is normal. No intervention is necessary.

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen b. Methylprednisolone c. Atropine sulfate d. Epinephrine

ANS: B Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.

The nurse teaches a client with Guillain-Barré syndrome (GBS) about the recovery rate of this disorder. Which statement indicates that the client correctly understands the teaching? a. "I need to see a lawyer because I do not expect to recover from this disease." b. "I will have to take things slowly for several months after I leave the hospital." c. "I expect to be able to return to work in construction soon after I get discharged." d. "I wonder if my family will be able to manage my care now that I am paralyzed."

ANS: B Most clients make a full recovery from GBS. Recovery can take as long as 6 months to 2 years. Fatigue is a major lingering symptom for most of those diagnosed with this disorder. Clients are not permanently paralyzed. They are in an acute care environment during the acute phase of the disorder.

The nurse is caring for a client who is able to flex the right arm forward without difficulty or pain but is unable to abduct the arm because of pain and muscle spasms. Which condition does the nurse suspect based on these assessment findings? a. Dislocated elbow b. Lesion in the rotator cuff c. Osteoarthritis of the shoulder d. Atrophy of the supraspinatus muscle

ANS: B Rotator cuff lesions may cause limited range of motion and pain and muscle spasm during abduction, whereas forward flexion stays fairly normal. The assessment findings are not consistent with the other conditions.

A client suspected to have myasthenia gravis is scheduled for the Tensilon (edrophonium chloride) test. Which prescribed medication does the nurse prepare to administer if complications of this test occur? a. Epinephrine b. Atropine sulfate c. Diphenhydramine d. Neostigmine bromide

ANS: B Tensilon increases cholinergic responses and can slow the heart rate down so that ectopic beats dominate, causing cardiac fibrillation or arrest. Atropine sulfate is an anticholinergic drug. The other medications are not appropriate for complications of this test.

The nurse is assessing a client who is experiencing a myasthenia crisis. Which diagnostic test does the nurse anticipate being ordered? a. Babinski reflex test b. Tensilon test c. Cholinesterase challenge test d. Caloric reflex test

ANS: B The Tensilon test in an important procedure for a client in myasthenic crisis. Cholinesterase-inhibiting drugs should be withheld because they increase respiratory secretions, which enhance the manifestations of a myasthenic crisis. A Babinski reflex and caloric reflex test would not be appropriate for this client.

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching? a. "Take warm baths to promote muscle relaxation." b. "Avoid crowds and people with colds." c. "Relying on a walker will weaken your gait." d. "Take prescribed medications when symptoms occur."

ANS: B The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the client's symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.

The nurse assesses a client with Guillain-Barré syndrome during plasmapheresis. Which complication does the nurse monitor for during this procedure? a. Tachycardia b. Hypovolemia c. Hyperkalemia d. Hemorrhage

ANS: B The client undergoing plasmapheresis is at risk for hypovolemia. The nurse monitors fluid status, assesses vital signs, and administers replacement fluid, as indicated. The other manifestations are not complications of plasmapheresis.

The nurse is obtaining a health history for a 45-year-old woman with Guillain-Barré syndrome (GBS). Which statement by the client does the nurse correlate with the client's diagnosis? a. "My neighbor also had Guillain-Barré syndrome." b. "I had a viral infection about 2 weeks ago." c. "I am an artist and work with oil paints." d. "I have a history of a cardiac dysrhythmia."

ANS: B The client with GBS often relates a history of acute illness, trauma, surgery, or immunization 1 to 3 weeks before the onset of neurologic symptoms. The other statements do not correlate with GBS.

An occupational therapist is treating a client with rheumatoid arthritis. Which assessment finding in the client does the nurse share with the occupational therapist? a. Difficulty sleeping because of pain in the knees and elbows b. Difficulty tying shoelaces and doing zippers on clothing c. Swollen knees with crepitus and limited range of motion d. Generalized joint stiffness that is worse in the early morning

ANS: B The functional assessment helps nurses and therapists measure how functional the client is with activities of daily living, including dressing. The occupational therapist can assist the client to explore clothing options that are easier to manage with arthritic fingers. The other findings would not necessarily need to be shared with the occupational therapist for the treatment plan.

The nurse is caring for a client who has myasthenia gravis. Which nursing intervention does the nurse implement to reduce muscle weakness in this client? a. Administer a therapeutic massage. b. Collaborate with the physical therapist. c. Perform passive range-of-motion exercises. d. Reposition the client every 2 hours.

ANS: B The hallmark of myasthenia gravis is muscle weakness that increases with fatigue. The nurse provides assistance with ADLs to prevent fatigue. The nurse collaborates with the physical therapist in teaching the client energy conservation techniques. Therapeutic massage, passive range of motion, and repositioning will not reduce muscle weakness.

The nurse is preparing a staff in-service program related to restless legs syndrome (RLS). Which potential risk factors of this syndrome does the nurse include? (Select all that apply.) a. Skin rashes b. Polyneuropathies c. Muscle atrophy d. Diabetes mellitus type 2 e. Hypercalcemia

ANS: B, D Risk factors for RLS include a possible genetic basis, history of type 2 diabetes mellitus, advanced kidney failure, vitamin and mineral deficiencies, polyneuropathies, peripheral nerve disease, age, lack of exercise, and pinched nerve. Rashes, muscle atrophy, and hypercalcemia are not related.

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction.

ANS: B, D, F For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client that includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a.Pupil size b.Grip strength c.Respiratory effort d.Level of consciousness

ANS: C Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

The nurse is assessing a client who is suspected of having muscular dystrophy. Which statement by the client indicates that more teaching may be needed about the creatine kinase (CK) test that the health care provider has ordered? a. "The Lasix that I took this morning may affect the test results." b. "The CK test is 90% accurate in demonstrating muscle trauma or injury." c. "The level of CK will be decreased with skeletal muscle disease." d. "When muscle is damaged, CK isoenzymes are released over time."

ANS: C All of the statements are correct, except that the level of creatine kinase will increase with any skeletal muscle damage.

The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important? a. Administering anxiolytics b. Having a ventilator nearby c. Obtaining atropine sulfate d. Sedating the client

ANS: C Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator is not necessary to have nearby, although emergency equipment should be available.

A client is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority? a. Bladder control b. Cognitive perception c. Respiratory system d. Sensory functions

ANS: C Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.

9. A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate. Which information will the nurse include in patient teaching? a. Recommendation to drink at least 4 L of fluid daily b.Need to avoid driving or operating heavy machinery c.How to draw up and administer injections of the medication d.Use of contraceptive methods other than oral contraceptives

ANS: C Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

ANS: C Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod For which adverse effect should the nurse monitor? a. Peripheral edema b. Black tarry stools c. Bradycardia d. Nausea and vomiting

ANS: C Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.

A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this client's plan of care? a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers.

ANS: C Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.

A client who has Guillain-Barré syndrome is scheduled for plasmapheresis. Before the procedure, which clinical manifestation does the nurse use to determine patency of the client's arteriovenous shunt? a. Palpable distal pulses b. A pink, warm extremity c. The presence of a bruit d. Shunt pressure higher than 25 mm Hg

ANS: C Nursing care of the client undergoing plasmapheresis includes care of the shunt. The nurse checks for bruits every 2 to 4 hours for patency. Pulse and extremity assessments do not provide information related to shunt patency. Pressure within the shunt is not tested before treatment to determine patency.

A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A 36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a walker

ANS: C Osteoarthritis causes changes to support structures, increasing the client's risk for low back pain. The other clients are not at high risk.

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let the provider know." b. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

ANS: C Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs.

A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center? a. "Avoid having teeth pulled for 1 year." b. "Brush your teeth with a soft toothbrush." c. "Do not use harsh chemicals on your face." d. "Inform your dentist of this procedure."

ANS: C The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the face because he or she will not feel burning or stinging on that side. This will help avoid injury. The other instructions are not necessary.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.

The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan? a. "Cut all calluses and corns from your feet as soon as you notice them." b. "Your balance will be steadier if you go barefoot while at home." c. "Use a thermometer to check the temperature of bath water." d. "Avoid using lotion on the feet and legs."

ANS: C The client with neuropathy has loss of sensation in the lower extremities, which can predispose the client to thermal injury. The client should be instructed to use a thermometer to check the temperature of the bath water to avoid a burn. Checking the water with the hands is not recommended because neuropathy may have a stocking and glove distribution that could also affect the hands. The client should be taught to wear shoes at all times, to assess feet and legs daily, to keep skin moist and clean, and not to cut calluses or corns from the feet.

The nurse assesses a client who has Guillain-Barré syndrome. Which clinical manifestation does the nurse expect to find in this client? a. Ophthalmoplegia and diplopia b. Progressive weakness without sensory involvement c. Progressive, ascending weakness and paresthesia d. Weakness of the face, jaw, and sternocleidomastoid muscles

ANS: C The most common clinical pattern of Guillain-Barré syndrome is the ascending variety. Weakness and paresthesia begin in the lower extremities and progress upward. The other manifestations are not associated with Guillain-Barré syndrome.

A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

ANS: C The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.

The nurse is caring for a client who presents with achy jaw pain. Which assessment technique does the nurse use to determine whether the client has inflammation of the temporomandibular joint (TMJ)? a. Checking for decayed, fractured, loose, or missing teeth b. Observing the jaw joint as the client chews a piece of food c. Palpating the joint during movement for tenderness or crepitus d. Observing for asymmetric joint protrusion when the client's mouth is closed

ANS: C The temporomandibular joints are best assessed by palpation while the client opens his or her mouth. The other assessment techniques are not effective for assessing possible TMJ inflammation.

A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache

ANS: C, D, E Bulging at the incision site or clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebral spinal fluid may cause a sudden and severe headache, which is also an emergency situation. Pain, redness, and itching at the site are normal.

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

ANS: C, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

ANS: C, E Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum.

10. Which information about a 60-year-old patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine ? a.The patient has relapsing-remitting MS. b.The patient walks a mile a day for exercise. c.The patient complains of pain with neck flexion. d.The patient has an increased serum creatinine level.

ANS: D Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.

A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How should the nurse respond? a. "You should discuss this with your family and health care provider." b. "Why are you afraid of being placed on a breathing machine?" c. "Using the incentive spirometer each hour will delay the need for a ventilator." d. "What would you like to be done if you begin to have difficulty breathing?"

ANS: D ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must indicate in the advance directive what is to be done when breathing is no longer possible without intervention. The other statements do not address the client's needs.

The nurse is teaching a client who is receiving carbamazepine for chronic trigeminal neuralgia. Which statement indicates that the client correctly understands the teaching? a. "This drug will prevent seizures, which can occur because of trigeminal disease." b. "I expect to have surgery soon, so I can stop taking this drug now." c. "This medication is very successful in relieving pain. I am glad to be taking it." d. "I will avoid drinking alcohol because it can add to the side effects of this medicine."

ANS: D Carbamazepine is thought to interfere with the transmission of pain through slow fibers. It may decrease the paroxysmal afferent impulse that causes trigeminal pain. Trigeminal disease does not cause seizures. Drowsiness, dizziness, confusion, and risk for falls are adverse effects of this medication. Alcohol consumption increases these risks; therefore the client should not drink alcohol when taking this medication. Seizure disorders may occur in clients who stop taking this medication. The dose should be decreased gradually. Pain relief varies with the person; some people find that this medication provides at least some relief.

Which postoperative order does the nurse clarify with the surgeon before discharging the client who just had arthroscopic surgery on the right knee? a. Keep the right leg elevated on a soft pillow for 12 hours. b. Maintain non-weight bearing by right leg for 48 hours. c. Use ice on the knee for 24 hours. d. Administer two tablets of oxycodone/APAP (Tylox) every 4 hours for pain.

ANS: D Each tablet of Tylox has 5 mg oxycodone with 500 mg acetaminophen. If the client took two tablets every 4 hours, the client would ingest a total of 6000 mg of acetaminophen, well over the safe maximum dose of 4000 mg in 24 hours. The rest of the orders are appropriate.

Which instruction does the nurse give to the client before he or she has electromyography (EMG)? a. "Make sure that you have someone to drive you home after the test." b. "Do not eat or drink anything for at least 6 hours before the test." c. "You will have to avoid heavy lifting for 24 hours following the test." d. "Do not take your cyclobenzaprine (Flexeril) on the 2 days before the test."

ANS: D Electromyography (EMG) testing measures nerve signal transmission to and through muscles. Skeletal muscle relaxants such as Flexeril can affect test results and should be avoided for at least 2 days before the test. The other instructions are not relevant before EMG testing.

The nurse is caring for a client who is to have a computed tomography (CT) scan of the leg. Which assessment question does the nurse ask the client before the procedure? a. "Do you have any metal clips, plates, or pins in your body?" b. "Have you had anything to eat or drink in the last 6 hours?" c. "Do you have someone to drive you home after the procedure?" d. "Do you have any allergies to shrimp, scallops, or other seafood?"

ANS: D IV contrast that contains iodine may be required for CT scans to rule out malignancy. The client should be assessed for allergy to shellfish, which contain high amounts of iodine. The other questions are not relevant when a CT scan is to be obtained.

A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

ANS: D In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching? a. "Stroke the inner aspect of your thigh to initiate voiding." b. "Use a clean technique for intermittent catheterization." c. "Implement digital anal stimulation when your bladder is full." d. "Tighten your abdominal muscles to stimulate urine flow."

ANS: D In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and digital anal stimulation do not initiate voiding or bladder control.

A client with trigeminal neuralgia is about to undergo surgery for pain relief. The client asks, "How will this surgery relieve my pain?" How does the nurse respond? a. "The surgeon will cut the connection between the cranial nerves." b. "The surgeon will use an electrode to bypass the trigeminal nerve conduction." c. "An incision is made into the nerve itself, and an anesthetic is applied to the area." d. "A small artery compressing the nerve will be relocated."

ANS: D In some clients, a small artery compresses the nerve as it enters the pons. By relocating this nerve, pain relief is obtained and sensation is spared. The other responses do not answer the client's question appropriately.

A client in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000/mm3, magnesium 0.8 mEq/L, and sodium 138 mEq/L. What action by the nurse is best? a. Advise the client to restrict fluids. b. Assess the client for signs of infection. c. Have the client add table salt to food. d. Instruct the client on a magnesium supplement.

ANS: D Iron and magnesium deficiencies can sometimes exacerbate or increase symptoms of restless leg syndrome. The client's magnesium level is low, and the client should be advised to add a magnesium supplement. The other actions are not needed.

A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test? a. Implement nothing by mouth (NPO) status for 8 hours. b. Withhold all daily medications until after the examination. c. Administer morphine sulfate to prevent claustrophobia during the test. d. Place the client in a gown that has cloth ties instead of metal snaps.

ANS: D Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen b. Interferon beta-1b c. Dantrolene sodium d. Methylprednisolone

ANS: D Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

ANS: D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.

A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met? a. Ability to chew and swallow without aspiration b. Eating 75% of meals and between-meal snacks c. Intake greater than output 3 days in a row d. Weight gain of 3 pounds in 1 month

ANS: D Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed. Swallowing without difficulty indicates an intact airway. Since the question does not indicate what the client's meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.