Med surge 5

The nurse is admitting a client to the unit who is diagnosed with a lower motor neuron lesion. What entry in the client's electronic record is most consistent with this diagnosis?

"Client demonstrates an absence of deep tendon reflexes."

A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test?

"You will need to lie still throughout the procedure."

A nurse is caring for a client who has been scheduled for a bone scan. What should the nurse teach the client about this diagnostic test?

"You'll be encouraged to drink water after the administration of the radioisotope injection."

The nurse is caring for a client who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve?

Acoustic

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis?

An elderly client with an infected pressure ulcer in the sacral area

A nurse is providing care for a client whose pattern of laboratory testing reveals long-standing hypocalcemia. What other laboratory result is most consistent with this finding?

An elevated parathyroid hormone level

An older adult client has symptoms of osteoporosis and is being assessed during her annual physical examination. The assessment shows that the client will require further testing related to a possible exacerbation of her osteoporosis. The nurse should anticipate what diagnostic test?

Bone densitometry

A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation?

Calcitonin

A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply.

Calcium, Vitamin D,

A client exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this client's health problem?

Cerebellar dysfunction

A client who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge?

Client can demonstrate safe use of assistive devices.

The nurse is performing an assessment of a client's musculoskeletal system and is appraising the client's bone integrity. What action should the nurse perform during this phase of assessment?

Compare parts of the body symmetrically

A nurse is performing a musculoskeletal assessment of a client with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of what assessment finding?

Crepitus

A nurse is caring for a client who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure should the nurse implement to control the edema?

Elevate the foot on several pillows

A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals?

Encouraging the client to turn from side to side and to assume a prone position

A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication?

Fat embolism syndrome

A client is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this client, the nurse has the client stick out her tongue and move it back and forth. What is the nurse assessing?

Function of the hypoglossal nerve

A nurse is caring for a client diagnosed with Ménière disease. While completing a neurologic examination on the client, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what?

Hearing and equilibrium

A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following?

Hypothalamus

A client has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication?

Inadequate immobilization

A nurse is caring for a client who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the client does what action to prevent common complications associated with a hip fracture?

Increase fluid intake and perform prescribed foot exercises

An older adult woman's current medication regimen includes alendronate. What outcome would indicate successful therapy?

Increased bone mass

A client has been experiencing an unexplained decline in knee function and has consequently been scheduled for arthrography. The nurse should teach the client about what process?

Injection of a contrast agent into the knee joint prior to ROM exercises

A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the nurse knows to include what in client teaching? Select all that apply.

Inspect the lower extremities for skin breakdown., Footwear needs to be accurately sized., Assistive devices may be needed to reduce the risk of falls.

The nurse's comprehensive assessment of an older adult involves the assessment of the client's gait. How should the nurse best perform this assessment?

Instruct the client to walk away from the nurse for a short distance and then toward the nurse

A nurse is discussing conservative management of tendonitis with a client. What is the nurse's best recommendation?

Intermittent application of ice and heat

The results of a nurse's musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem?

Lordosis

The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment?

Loss of voluntary control of movement

A nurse is preparing to discharge a client from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage what action?

Maintain the ankle in a dependent position

A nurse is caring for a client who has suffered an unstable thoracolumbar fracture. What goal should the nurse prioritize during nursing care?

Maintaining spinal alignment

A client has sustained a long bone fracture and the nurse is preparing the client's care plan. Which of the following should the nurse include in the care plan?

Monitor temperature and pulses of the affected extremity

An older adult client experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply.

Muscle weakness, Adverse medication effects,Slowed reflexes, Loss of visual acuity

When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII?

Observe for facial movement symmetry, such as a smile

A client with diabetes is attending a class on the prevention of associated diseases. What action should the client perform to reduce the risk of osteomyelitis?

Perform meticulous foot care

What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture?

Place a pillow between the client's legs when turning

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware?

Reduction in cerebral blood flow

A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action?

Removing all metal-containing objects

A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply.

Resting the affected extremity, Elevating the injured limb, Applying ice, Compression dressings

A nurse's assessment of a teenage girl reveals that her shoulders are not level and that she has one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the client's electronic health record?

Scoliosis

A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What risk factor of the following should the educator describe?

Small frame and female gender

A nurse is explaining a client's decreasing bone density in terms of the balance between bone resorption and formation. What dietary nutrients and hormones play a role in the resorption and formation of adult bones? Select all that apply.

Thyroid hormone, Growth hormone, Estrogen

What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I?

Utilize the Snellen chart

A nurse is planning the care of an older adult client who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage what actions? Select all that apply.

Weight-bearing exercise, Use of falls prevention precautions, Regular bone density testing,

A client has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse perform following this procedure?

Wrap the joint in a compression dressing

An older adult client has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the client's spine. The nurse should document the presence of:

kyphosis.