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.You have just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6° F (39.2° C) orally. Which prescribed intervention should be implemented first? 1. Administer codeine 15 mg orally for the client's headache. 2. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. 3. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever. 4. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.

Ans: 2 Bacterial meningitis is a medical emergency, and antibiotics are administered even before the diagnosis is confirmed (after specimens have been collected for culture). The other interventions will also help to reduce central nervous system stimulation and irritation and should be implemented as soon as possible, but are not as important as starting antibiotic therapy

.You are floated from the ED to the neurologic floor. Which action should you delegate to the UAP when providing nursing care for a client with an SCI? 1. Assessing the client's respiratory status every 4 hours 2. Taking the client's vital signs and recording every 4 hours 3. Monitoring the client's nutritional status, including calorie counts 4. Instructing the client how to turn, cough, and breathe deeply every 2 hours

Ans: 2 The UAP's training and education covers measuring and recording vital signs. The UAP may help with turning and repositioning the client and may remind the client to cough and deep breathe, but he or she does not teach the client how to perform these actions. Assessing and monitoring clients require additional education and are appropriate to the scope of practice of professional nurses

.The UAP reports to you, the RN, that a client with myasthenia gravis has an elevated temperature (102.2° F [39° C]), an increased heart rate (120 beats/min), and a rise in blood pressure (158/94 mm Hg) and was incontinent of urine and stool. What is your best first action at this time? 1. Administer an acetaminophen suppository. 2. Notify the physician immediately. 3. Recheck vital signs in 1 hour. 4. Reschedule the client's physical therapy.

Ans: 2 The changes that the UAP is reporting are characteristic of myasthenic crisis, which often follows some type of infection. The client is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the client's respiratory status. The client may need intubation and mechanical ventilation.

.A 70-year-old alcoholic client who has become lethargic, confused, and incontinent during the last week is admitted to the ED. His wife tells you that he fell down the stairs about a month ago, but that "he didn't have a scratch afterward." Which collaborative interventions will you implement first? 1. Place the client on the hospital alcohol withdrawal protocol. 2. Transport the client to the radiology department for a computed tomographic (CT) scan. 3. Make a referral to the social services department. 4. Give the client phenytoin 100 mg PO.

Ans: 2 The client's history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the client to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward diagnosis and treatment of any intracranial lesion

.A client who has Alzheimer disease is hospitalized with new-onset angina. Her husband tells you he does not sleep well because he needs to be sure she does not wander during the night. He insists on checking each of the medications you give the client to be sure they are "the same pills she takes at home." Based on this information, which nursing diagnosis is most appropriate for this client? 1. Decreased Cardiac Output related to poor myocardial contractility 2. Caregiver Role Strain related to continuous need for providing care 3. Risk for Falls related to client wandering behavior during the night 4. Ineffective Family Therapeutic Regimen Management related to poor client memory

Ans: 2 The husband's statement about lack of sleep and anxiety about whether his wife is receiving the correct medications are behaviors that support this diagnosis. There is no evidence that the client's cardiac output is decreased. The husband's statements about how he monitors the client and his concern with medication administration indicate that the risk for ineffective family therapeutic regimen management and falls are not priority diagnoses at this time.

.Which client should you, as charge nurse, assign to a new RN graduate who is on orientation to the neurologic unit? 1. 28-year-old newly-admitted client with an SCI 2. 67-year-old who had a stroke 3 days ago and has left-sided weakness 3. 85-year-old with dementia who is to be transferred to long-term care today 4. 54-year-old with Parkinson disease who needs assistance with bathing

Ans: 2 The new RN graduate who is on orientation to the unit should be assigned to care for clients with stable, noncomplex conditions, such as the client with stroke. The task of helping the client with Parkinson disease to bathe is best delegated to the UAP. The client being transferred to the nursing home and the newly-admitted client with SCI should be assigned to experienced nurses

.Which client should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? 1. 34-year-old with newly diagnosed multiple sclerosis (MS) 2. 68-year-old with chronic amyotrophic lateral sclerosis (ALS) 3. 56-year-old with Guillain-Barré syndrome (GBS) in respiratory distress 4. 25-year-old admitted with a C4-level SCI

Ans: 2 The traveling nurse is relatively new to neurologic nursing and should be assigned clients whose condition is stable and not complex, such as the client with chronic ALS. The newly-diagnosed client with MS will need a lot of teaching and support. The client with respiratory distress will need frequent assessments and may need to be transferred to the intensive care unit. The client with a C4-level SCI is at risk for respiratory arrest. All three of these clients should be assigned to nurses experienced in neurologic nursing care

.A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should you take first? 1. Administer the ordered acetaminophen (Tylenol). 2. Check the Foley tubing for kinks or obstruction. 3. Adjust the temperature in the client's room. 4. Notify the physician about the change in status.

Ans: 2 These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, and fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful, because too cool a temperature in the room may contribute to the problem. Acetaminophen will not decrease the autonomic dysreflexia that is causing the client's headache. Notifying the physician may be necessary if nursing actions do not resolve symptoms.

.You are interviewing an elderly woman and discover that she has been taking her glaucoma eyedrops by mouth for the past week. What should you do first? 1. Call to obtain an order for tonometry so that her intraocular pressure can be checked. 2. Try to determine how frequently and how much she has been ingesting. 3. Ask her how she decided to take the drops orally instead of instilling them as eyedrops. 4. Call the Poison Control Center and be prepared to describe untoward side effects

Ans: 2 Try to find out how much and how frequently she has been taking the drops by mouth. This information will be needed if you call the ophthalmologist for an order or if you call Poison Control. A good follow-up question is to try to find out why she is taking the drops by mouth. She may be very confused, or there may have been an error of omission in client education by all health care team members who were involved in the initial prescription.

.Which physical assessment findings should be reported to the physician? 1. Pearly gray or pink tympanic membrane 2. Dense whitish ring at the circumference of the tympanum 3. Bulging red or blue tympanic membrane 4. Cone of light at the innermost part of the tympanum

Ans: 3 A bulging red or blue tympanic membrane is a possible sign of otitis media or perforation. The other signs are considered normal anatomy

.Which client in the neurologic ICU will be best to assign to an RN who has been floated from the medical unit? 1. 26-year-old with a basilar skull fracture who has clear drainage coming out of the nose 2. 42-year-old admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm 3. 46-year-old who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due 4. 65-year-old with an astrocytoma who has just returned to the unit after undergoing craniotomy

Ans: 3 Of the clients listed, the client with bacterial meningitis is in the most stable condition. An RN from the medical unit would be familiar with administering IV antibiotics. The other clients require assessments and care from RNs more experienced in caring for clients with neurologic diagnoses

.A client with Parkinson disease has received a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe the UAP performing all of these actions. For which action must you intervene? 1. Helping the client ambulate to the bathroom and back to bed 2. Reminding the client not to look at his feet when he is walking 3. Performing the client's complete bathing and oral care 4. Setting up the client's tray and encouraging the client to feed himself

Ans: 3 The UAP should help the client with morning care as needed, but the goal is to keep this client as independent and mobile as possible. The client should be encouraged to perform as much morning care as possible. Assisting the client in ambulating, reminding the client not to look at his feet (to prevent falls), and encouraging the client to feed himself are all appropriate to the goal of maintaining independence.

.A client with MS tells the UAP after physical therapy that she is too tired to take a bath. What is the priority nursing diagnosis at this time? 1. Fatigue related to disease state 2. Activity Intolerance due to generalized weakness 3. Impaired Physical Mobility related to neuromuscular impairment 4. Bathing Self-Care Deficit related to fatigue and neuromuscular weakness

Ans: 4 At this time, based on the client's statement, the priority is Bathing Self-Care Deficit related to fatigue after physical therapy. The other three nursing diagnoses are appropriate to a patent with MS but are not related to the client's statement.

.In discharge teaching after cataract surgery, the client and family should be told to immediately report which symptom to the physician? 1. A scratchy sensation in the operative eye 2. Loss of depth perception with the patch in place 3. Poor vision 6-8 hours after patch removal 4. Pain not relieved by prescribed medications

Ans: 4 Pain may signal hemorrhage, infection, or increased ocular pressure. A scratchy sensation and loss of depth perception with the patch in place are not uncommon. Adequate vision may not return for 24 hours

.A client with an SCI at level C3-C4 is being cared for in the emergency department (ED). What is the priority assessment? 1. Determine the level at which the client has intact sensation. 2. Assess the level at which the client has retained mobility. 3. Check blood pressure and pulse for signs of spinal shock. 4. Monitor respiratory effort and oxygen saturation level.

Ans: 4 The first priority for the client with an SCI is assessing respiratory patterns and ensuring an adequate airway. A client with a high cervical injury is at risk for respiratory compromise, because spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary but are not as high a priority

.An LPN/LVN, under your supervision, is providing nursing care for a client with GBS. What observation should you instruct the LPN/LVN to report immediately? 1. Reports of numbness and tingling 2. Facial weakness and difficulty speaking 3. Rapid heart rate of 102 beats/min 4. Shallow respirations and decreased breath sounds

Ans: 4 The priority intervention for a client with GBS is maintaining adequate respiratory function. Clients with GBS are at risk for respiratory failure, which requires urgent intervention. The other findings are important and should be reported to the nurse, but they are not life threatening. F

.After you receive the change-of-shift report at 7:00 am, which client will you assess first? 1. 23-year-old with a migraine headache who reports severe nausea associated with retching 2. 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching 3. 59-year-old with Parkinson disease who will need a swallowing assessment before breakfast 4. 63-year-old with MS who has an oral temperature of 101.8° F (38.8° C) and flank pain one (Deca

Ans: 4 Urinary tract infections (UTIs) are a frequent complication in clients with MS because of the effect of the disease on bladder function, and UTIs may lead to sepsis in these clients. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The physician should be notified immediately so that IV antibiotic therapy can be started quickly. The other clients should be assessed as soon as possible, but their needs are not as urgent as those of this client

10.4 A client with a T2-to-T3 spinal cord injury suddenly complains of a throbbing headache and blurred vision. The nurse assesses that he is fl ushed and sweating on his upper trunk and face, and the hairs on his arms are raised. What should the nurse do fi rst? ■ 1. Raise the head of the bed. ■ 2. Assess for hypotension. ■ 3. Check the client for a distended bladder. ■ 4. Logroll the client to see if he is lying on a foreign object.

. 1. The client with a spinal cord injury above T6 who suddenly experiences clinical manifestations of autonomic stimulation, such as fl ushing, sweating, and pilocarpia, is demonstrating lifethreatening autonomic dysrefl exia. The cluster of manifestation results from noxious stimuli, such as a full bladder, or lying on a foreign object, such as a plastic cap or crinkled paper, which the client cannot feel. As soon as the noxious stimulus is removed, the manifestations begin to subside. When the client demonstrates clinical manifestations of autonomic dysrefl exia, the nurse should fi rst elevate the head of the bed immediately to decrease the intracerebral pressure caused by the hypertension that developed from autonomic stimulation. The nurse can next check for a distended bladder or foreign object. The client's blood pressure will be elevated; the nurse should assess vital signs frequently

A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and fl u for the past 5 days. Within 1 hour of admission, the client states that his legs are numb all the way up to his hips. The nurse should do which of the following next? Select all that apply. ■ 1. Call his family to come in to visit with him. ■ 2. Notify his health care provider of the change. ■ 3. Place respiratory resuscitation equipment in the client's room. ■ 4. Check for advancing levels of paresthesia. ■ 5. Perform ankle pumps to increase circulation and relieve numbness

. 2, 3, 4. A client who has been admitted for numbness and tingling in his lower extremities that advances upward, especially after having a viral infection, has clinical manifestations characteristic of Guillain-Barré syndrome. The health care provider must be notifi ed of the change immediately because this disease is progressively paralytic and should be treated before paralysis of the respiratory muscles occurs. The nurse must assess the client continuously to determine how fast the paralysis is advancing. The family does not need to be called in to visit until the client is stabilized and emergency equipment is placed at the bedside. Performing ankle pumps will not relieve the numbness or change the course of the disease

84. A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which of the following measures would be most benefi cial? 1. Psychotherapy. ■ 2. Regular exercise. ■ 3. Day care for the granddaughter. 4. Weekly visits by another person with MS.

. 2. An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients

. The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations? ■ 1. Inappropriate laughter. ■ 2. An exaggerated sense of well-being. ■ 3. Slurring of words when excited. ■ 4. Visual hallucinations

. 2. A client with multiple sclerosis may have a sense of optimism and euphoria, particularly during remissions. Euphoria is characterized by mood elevation with an exaggerated sense of well-being. Inappropriate laughter, slurring of words, and visual hallucinations are uncharacteristic of euphoria.

112. The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which one of the following interventions should the nurse consider? ■ 1. Have the client hyperextend the neck when swallowing. ■ 2. Tell the client to place the chin fi rmly against the chest when eating. ■ 3. Thicken all liquids before offering to the client. ■ 4. Place the client on a clear liquid diet.

. 3. Clients with Parkinson's disease can experience dysphagia. Thickening liquids assists with swallowing, preventing aspiration. Hyperextending the neck opens the airway and can increase risk of aspiration. Pressing the chin fi rmly on the chest makes swallowing more diffi cult. The chin should be slightly tucked to promote swallowing. The nurse should suggest a speech therapy consult for evaluation of the client's ability to swallow.

21. The expected outcome of using miotics to treat glaucoma is: ■ 1. Paralyzing ciliary muscles. ■ 2. Constricting intraocular vessels. ■ 3. Constricting the pupil. ■ 4. Relaxing ciliary muscles.

. 3. A miotic agent constricts the pupil and contracts ciliary musculature. These effects widen the fi ltration angle and permit increased outfl ow of aqueous humor. Miotics also cause vasodilation of the intraocular vessels, where intraocular fl uids leave the eye, also increasing aqueous humor outfl ow. Mydriatics cause cycloplegia, or paralysis of the ciliary muscle

26. A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plans the client's nursing care with the understanding that acute angle-closure glaucoma: ■ 1. Frequently resolves without treatment. ■ 2. Is typically treated with sustained bed rest. ■ 3. Is a medical emergency that can rapidly lead to blindness. ■ 4. Is most commonly treated with steroid therapy

. 3. Acute angle-closure glaucoma is a medical emergency that rapidly leads to blindness if left untreated. Treatment typically involves miotic drugs and surgery, usually iridectomy or laser therapy. Both procedures create a hole in the periphery of the iris, which allows the aqueous humor to fl ow into the anterior chamber. Bed rest does not affect the progression of acute angle-closure glaucoma. Steroids are not a treatment for acute angle-closure glaucoma; in fact, they are associated with the development of glaucoma.

23. A client uses timolol maleate (Timoptic) eyedrops. The expected outcome of this beta-adrenergic blocker is to control glaucoma by: ■ 1. Constricting the pupils. ■ 2. Dilating the canals of Schlemm. ■ 3. Reducing aqueous humor formation. ■ 4. Improving the ability of the ciliary muscle to contract.

. 3. Timolol maleate (Timoptic) is commonly administered to control glaucoma. The drug's action is not completely understood, but it is believed to reduce aqueous humor formation, thereby reducing intraocular pressure. Timolol does not constrict the pupils; miotics are used for pupillary constriction and contraction of the ciliary muscle. Timolol does not dilate the canal of Schlemm

45. A client has vertigo. Which of the following actions would be most appropriate for the nursing diagnosis of Risk for injury related to altered immobility and gait disturbances? Select all that apply. ■ 1. The client assumes safe position when dizzy. ■ 2. The client experiences no falls. ■ 3. The client performs vestibular/balance exercises. ■ 4. The client demonstrates family involvement. ■ 5. The client keeps head still when dizzy.

1, 2, 3, 5. Assessment of vertigo, including history, onset, description of attacks, duration, frequency, and associated ear symptoms, is important. Vestibular/balance therapy or exercises should be taught and practiced. The client needs to be instructed to sit down when dizzy and decrease the amount of head movement. The client will benefi t from recognizing whether he or she experiences an "aura" before an attack so appropriate action can be taken. Finally, it is recommended that the client keep the eyes open and look straight ahead when lying down. These expected outcomes will prevent the problem of injury. Family involvement is essential when dealing with a client experiencing vertigo but is not applicable for this particular nursing diagnosis.

. A nurse is taking a medication history on a client with multiple sclerosis before administering an initial dose of baclofen (Lioresal). What should the nurse check before administering the drug? Select all that apply. ■ 1. Presence of muscle weakness. ■ 2. History of muscle spasms. ■ 3. Serum creatinine level. ■ 4. Serum potassium level. ■ 5. Blood glucose

1, 2, 3, 5. The nurse should ask the client with multiple sclerosis about areas of muscle weakness because baclofen may increase the weakness. The nurse should ask the client about a history of muscle spasms. Baclofen is effective against involuntary spasms resistant to passive movement for clients with multiple sclerosis and paralysis. Baclofen is not effective against the spasticity of cerebral origin, such as with cerebral palsy and Parkinson's disease. The nurse should ask the client about his liver and renal function because baclofen is metabolized and excreted by these organs. The nurse should check the laboratory values refl ecting the function of the kidneys and liver, which include serum creatinine and blood urea nitrogen levels. The nurse should also check blood glucose levels because baclofen can increase blood glucose. Clients with diabetes taking antidiabetic medication may need to adjust the dosage. Potassium is not affected by the drug, so the nurse does not need to check the serum potassium level

2. A client is having a cataract removed and will use eyeglasses after the surgery. The nurse should develop a teaching plan that includes which of the following? Select all that apply. ■ 1. Images will appear to be one-third larger. ■ 2. Look through the center of the glasses. ■ 3. The changes will be immediate. ■ 4. Use handrails when climbing stairs. ■ 5. Stay out of the sun for 2 weeks.

1, 2, 4. The use of glasses following cataract surgery does not totally restore binocular vision. Glasses will cause images to appear larger and peripheral vision will be distorted; the client should look through the center of the glasses and turn his or her head to view objects in the periphery. The client should also use caution when walking or climbing stairs until he or she has adjusted to the change in vision. Changes in vision following cataract surgery are not immediate and the nurse can instruct the client to be patient while adjusting to the changes. The client does not need to stay out of the sun, but should wear dark glasses to prevent discomfort from photophobia.

82. Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. ■ 1. Carefully test the temperature of bath water. ■ 2. Avoid kitchen activities because of the risk of injury. ■ 3. Avoid hot water bottles and heating pads. ■ 4. Inspect the skin daily for injury or pressure points. ■ 5. Wear warm clothing when outside in cold temperatures.

1, 3, 4, 5. A client with impaired peripheral sensation does not feel pain as readily as someone whose sensation is unimpaired; therefore, water temperatures should be tested carefully. The client should be advised to avoid using hot water bottles or heating pads and to protect against cold temperatures. Because the client cannot rely on minor pain as an indicator of damaged skin or sore spots, the client should carefully inspect the skin daily to visualize any injuries that he cannot feel. The client should not be instructed to avoid kitchen activities out of fear of injury; independence and selfcare are also important. However, the client should meet with an occupational therapist to learn about assistive devices and techniques that can reduce injuries, such as burns and cuts that are common in kitchen activities.

A client with Parkinson's disease asks the nurse to explain to his nephew "what the doctor said the pallidotomy would do." The nurse's best response includes stating that the main goal for the client after pallidotomy is improved: 1. Functional ability. 2. Emotional stress. 3. Alertness. 4. Appetite.

1. The goal of a pallidotomy is to improve functional ability for the client with Parkinson's disease. This is a priority. The pallidotomy creates lesions in the globus pallidus to control extrapyramidal disorders that affect control of movement and gait. If functional ability is improved by the pallidotomy, the client may experience a secondary response of an improved emotional response, but this is not the primary goal of the surgical procedure. The procedure will not improve alertness or appetite

An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? 1. Establishing an airway. 2. Replacing blood loss. 3. Stopping bleeding from open wounds. 4. Checking for a neck fracture

1. The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established

9. The nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use? ■ 1. Remain in a semi-Fowler's position. ■ 2. Position the feet higher than the body. ■ 3. Lie on the operative side. ■ 4. Place the head in a dependent position.

1. The nurse should instruct the client to remain in a semi-Fowler's position or on the nonoperative side. Positioning the feet higher than the body does not affect the operative eye; placing the head in a dependent position could increase pressure within the eyes.

What is the primary goal collaboratively established by the client with Parkinson's disease, nurse, and physical therapist? 1. To maintain joint fl exibility. 2. To build muscle strength. 3. To improve muscle endurance. 4. To reduce ataxia.

1. The primary goal of physical therapy and nursing interventions is to maintain joint fl exibility and muscle strength. Parkinson's disease involves a degeneration of dopamine-producing neurons; therefore, it would be an unrealistic goal to attempt to build muscles or increase endurance. The decrease in dopamine neurotransmitters results in ataxia secondary to extrapyramidal motor system effects. Attempts to reduce ataxia through physical therapy would not be effective

46. The client with Ménière's disease is instructed to modify his diet. The nurse should explain that the most frequently recommended diet modifi cation for Ménière's disease is: ■ 1. Low sodium. ■ 2. High protein. ■ 3. Low carbohydrate. ■ 4. Low fat.

1. A low-sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Ménière's disease respond to treatment with a low-salt diet. A diuretic may also be ordered. Other dietary changes, such as high protein, low carbohydrate, and low fat, do not have an effect on Ménière's disease.

10. After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eyedrops. The rationale that supports applying pressure is that it: ■ 1. Prevents the medication from entering the tear duct. ■ 2. Prevents the drug from running down the client's face. ■ 3. Allows the sensitive cornea to adjust to the medication. ■ 4. Facilitates distribution of the medication over the eye surface

1. Applying pressure against the nose at the inner canthus of the closed eye after administering eyedrops prevents the medication from entering the lacrimal (tear) duct. If the medication enters the tear duct, it can enter the nose and pharynx, where it may be absorbed and cause toxic symptoms. Eyedrops should be placed in the eye's lower conjunctival sac. Applying pressure will not prevent the drug from running down the face as long as the drops are instilled in the eye. Pressure does not affect the cornea or facilitate distribution of the medication over the eye surface.

When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis? ■ 1. Improved muscle strength after I.V. administration of edrophonium chloride (Tensilon). ■ 2. Increased weakness. ■ 3. Diaphoresis. ■ 4. Increased salivation

1. Extreme muscle weakness is present in both cholinergic crisis and myasthenic crisis. In cholinergic crisis, I.V. edrophonium chloride (Tensilon), a cholinergic agent, does not improve muscle weakness; in myasthenic crisis, it does. Diaphoresis and increased salivation are not present in cholinergic crises.

The nurse is planning to teach the client with spinal cord injury and intermittent nasogastric suctioning about interventions to protect her integumentary system. The nurse should tell the client to: ■ 1. Eat enough calories to maintain desired weight. ■ 2. Stay in cool environments to avoid sweating. ■ 3. Stay in warm environments to avoid chilling. ■ 4. Eat low-sodium foods to avoid edema.

1. The client should eat enough calories to maintain her desired weight, a positive nitrogen balance, and enough protein to help decrease the rate of muscle atrophy and prevent skin breakdown and infection. The client with a spinal cord injury does not have poikilothermy, the ability to adjust body temperature to the environmental temperature. The client should add additional clothes or coverage below the level of transection in cool environments. The client does not sweat below the level of transection and should be sensitive to the possibility of overheating in extremely hot climates and the need for sprinkling or moving into an air-conditioned environment. The client with intermittent nasogastric suctioning is at risk for development of metabolic alkalosis and an electrolyte imbalance that leads to decreased tissue perfusion; therefore, the client needs to increase the sodium and potassium in her diet, not decrease the sodium

When assessing the client with a cord transection above T5 for possible complications, which of the following should the nurse expect as least likely to occur? ■ 1. Diarrhea. ■ 2. Paralytic ileus. ■ 3. Stress ulcers. ■ 4. Intra-abdominal bleeding

1. The client with a spinal cord transection above T5 is least likely to develop diarrhea. Rather, constipation due to atonia would be possible. The client with a spinal cord transection above T5 is at risk for development of a paralytic ileus because the sympathetic nerve innervation to the vagus nerve, which dominates all the vessels and organs below T5 (e.g., the intestinal tract), has been disrupted and therefore so has movement or peristalsis. The client is at risk for development of stress ulcers because the sympathetic nerve innervation to the stomach has been disrupted, which results in an excessive release of hydrochloric acid in the stomach, allowing contact of hydrochloric acid with the stomach mucosa. The client does not feel subjective signs of stress ulcers (e.g., pain, guarding, tenderness) and therefore is at increased risk for bleeding because complications of an ulcer can develop before early diagnosis

The nurse is planning care for aclient who has sustained a spinal cord injury. The nurse should assess the client for: ■ 1. Anesthesia below the level of the injury. ■ 2. Tingling in the fi ngers. ■ 3. Pain below the site of the injury. ■ 4. Loss of position and vibratory sense.

1. The spinal cord connects the brain to the periphery. Destruction or interruption of the neurosensory pathway results in loss of communication between the two systems. Transection of the spinal cord renders the individual in a complete state of anesthesia below the level of injury. Tingling in the fi ngers may be related to spinal cord disease or to improper positioning of the extremity. Loss of position and vibratory sense usually occurs when the individual has degeneration of the posterior column of the spinal cord.

The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply. 1. Restrict fluids to 1,000 mL/24 hours. 2. Drink 400 to 500 mL with each meal. 3. Drink fl uids midmorning, midafternoon, and late afternoon. 4. Attempt to void at least every 2 hours. 5. Use intermittent catheterization as needed.

2, 3, 4, 5. Maintaining urinary function in a client with neurogenic bladder dysfunction from MS is an important goal. The client should ideally drink 400 to 500 mL with each meal; 200 mL midmorning, midafternoon, and late afternoon; and attempt to void at least every 2 hours to prevent infection and stone formation. The client may need to catheterize herself to drain residual urine in the bladder. Restricting fl uids during the day will not produce suffi cient urine. However, in bladder training for nighttime continence, the client may restrict fl uids for 1 to 2 hours before going to bed. The client should drink at least 2,000 mL every 24 hours.

Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client? Select all that apply. 1. Back at the level of the client's scapula. 2. Back and head that are high. 3. Seat that is lower than normal. 4. Seat with fi rm cushions. 5. Chair controlled by the client's breath.

2, 3, 5. The client with a C3 to C4 fracture has neck control but may tire easily using sore muscles around the incision area to hold up his head. Therefore, the head and neck of his wheelchair should be high. The seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair. When a client can use his hands and arms to move the wheelchair, the placement of the back to the client's scapula is necessary. This client cannot use his arms and will need an electric chair with breath, chin, or voice control to manipulate movement of the chair. A fi rm or hard cushion adds pressure to bony prominences; the cushion should instead be padded to reduce the risk of pressure ulcers

A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his wife to the hospital to deliver their child. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated that the nurse will not turn on the television. What should the nurse do next? Select all that apply. 1. Find a television so the client can view the football game. 2. Determine if the client's pupils are equal and react to light. 3. Ask the client if he has a headache. 4. Arrange for the client to be with his wife and baby. 5. Administer a sedative

2, 3. The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to fi nd a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP

Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)? 1. Double vision. 2. Sudden bursts of energy. 3. Weakness in the extremities. 4. Muscle tremors.

2. With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS.

At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? 1. Early in the morning, when the client's energy level is high. 2. To coincide with the peak action of drug therapy. 3. Immediately after a rest period. 4. When family members will be available

2. Demanding physical activity should be performed during the peak action of drug therapy. Clients should be encouraged to maintain independence in self-care activities to the greatest extent possible. Although some clients may have more energy in the morning or after rest, tremors are managed with drug therapy.

A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? 1. The client exhibits intolerance to many drugs. 2. The client experiences spontaneous remissions from time to time. 3. The client requires multiple drugs simultaneously. 4. The client endures long periods of exacerbation before the illness responds to a particular drug.

2. Evaluating drug effectiveness is diffi cult because a high percentage of clients with MS exhibit unpredictable episodes of remission, exacerbation, and steady progress without apparent cause. Clients with MS do not necessarily have increased intolerance to drugs, nor do they endure long periods of exacerbation before the illness responds to a particular drug. Multiple drug use is not what makes evaluation of drug effectiveness diffi cult.

6. The nurse is to instill drops of phenylephrine hydrochloride (Neo-Synephrine) into the client's eye prior to cataract surgery. Which of the following is the expected outcome? ■ 1. Dilation of the pupil and blood vessels. ■ 2. Dilation of the pupil and constriction of blood vessels. ■ 3. Constriction of the pupil and constriction of blood vessels. ■ 4. Constriction of the pupil and dilation of blood vessels.

2. Instilled in the eye, phenylephrine hydrochloride (Neo-Synephrine) acts as a mydriatic, causing the pupil to dilate. It also constricts small blood vessels in the eye

A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which of the following indicates effective therapy? 1. Mood. 2. Muscle rigidity. 3. Appetite. 4. Alertness.

2. Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson's disease.

A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation? 1. Tell the client firmly that she needs assistance and help her with her care. 2. Praise the client for her desire to be independent and give her extra time and encouragement. 3. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help. 4. Suggest to the client that if she insists on selfcare, she should at least modify her routine

2. Ongoing self-care is a major focus for clients with Parkinson's disease. The client should be given additional time as needed and praised for her efforts to remain independent. Firmly telling the client that she needs assistance will undermine her self-esteem and defeat her efforts to be independent. Telling the client that her perception is unrealistic does not foster hope in her ability to care for herself. Suggesting that the client modify her routine seems to put the hospital or the nurse's time schedule before the client's needs. This will only decrease the client's self-esteem and her desire to try to continue self-care, which is obviously important to her

Which of the following is an initial sign of Parkinson's disease? 1. Rigidity. 2. Tremor. 3. Bradykinesia. 4. Akinesia.

2. The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia

4. The client with a cataract tells the nurse that she is afraid of being awake during eye surgery. Which of the following responses by the nurse would be the most appropriate? ■ 1. "Have you ever had any reactions to local anesthetics in the past?" ■ 2. "What is it that disturbs you about the idea of being awake?" ■ 3. "By using a local anesthetic, you won't have nausea and vomiting after the surgery." ■ 4. "There's really nothing to fear about being awake. You'll be given a medication that will help you relax."

2. The nurse should give a client who seems fearful of surgery an opportunity to express her feelings. Only after identifying the client's concerns can the nurse intervene appropriately. Asking the client about previous reactions to local anesthetics may be warranted, but it does not address the client's concerns in this instance. Telling the client that she will not have nausea or vomiting ignores the client's feelings of fear and does not provide any data about the client's feelings. More data would help the nurse plan care. Telling the client that there is nothing to be afraid of minimizes her feelings and does not address her concerns. Premature explanations and clichés do not provide needed assessment data and ignore the client's feelings.

81. The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client: ■ 1. "You will need to accept the necessity for a quiet and inactive lifestyle." ■ 2. "Keep active, use stress reduction strategies, and avoid fatigue." ■ 3. "Follow good health habits to change the course of the disease." ■ 4. "Practice using the mechanical aids that you will need when future disabilities arise."

2. The nurse's most positive approach is to encourage a client with MS to keep active, use stress reduction strategies, and avoid fatigue because it is important to support the immune system while remaining active. A quiet, inactive lifestyle is not necessarily indicated. Good health habits are not likely to alter the course of the disease, although they may help minimize complications. Practicing using aids that will be needed for future disabilities may be helpful but also can be discouraging

The nurse observes that a client's upper arm tremors disappear as he unbuttons his shirt. Which statement best guides the nurse's analysis of this observation about the client's tremors? 1. The tremors are probably psychological and can be controlled at will. 2. The tremors sometimes disappear with purposeful and voluntary movements. 3. The tremors disappear when the client's attention is diverted by some activity. 4. There is no explanation for the observation; it is probably a chance occurrence

2. Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson's disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client.

When the client has a cord transection at T4, which of the following is the primary focus of the nursing assessment? ■ 1. Renal status. ■ 2. Vascular status. ■ 3. Gastrointestinal function. ■ 4. Biliary function.

2. Although assessment of renal status, gastrointestinal function, and biliary function is important, with the spinal cord transection at T4 the client's vascular status is the primary focus of the nursing assessment because the sympathetic feedback system is lost and the client is at risk for hypotension and bradycardia.

11. To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid: ■ 1. Lying supine. ■ 2. Coughing. ■ 3. Deep breathing. ■ 4. Ambulation.

2. Coughing is contraindicated after cataract extraction because it increases intraocular pressure. Other activities that are contraindicated because they increase intraocular pressure include: turning to the operative side, sneezing, crying, and straining. Lying supine, ambulating, and deep breathing do not affect intraocular pressure.

19. A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, "How does glaucoma damage my eyesight?" The nurse's reply should be based on the knowledge that COAG: ■ 1. Results from chronic eye infl ammation. ■ 2. Causes increased intraocular pressure. ■ 3. Leads to detachment of the retina. ■ 4. Is caused by decreased blood fl ow to the retina

2. In COAG, there is an obstruction to the outfl ow of aqueous humor, leading to increased intraocular pressure. The increased intraocular pressure eventually causes destruction of the retina's nerve fi bers. This nerve destruction causes painless vision loss. The exact cause of glaucoma is unknown. Glaucoma does not lead to retinal detachment

18. A client with glaucoma is to receive 3 gtt of acetazolamide (Diamox) in the left eye. What should the nurse do? ■ 1. Ask the client to close his right eye while administering the drug in the left eye. ■ 2. Have the client look up while the nurse administers the eyedrops. ■ 3. Have the client lift his eyebrows while the nurse positions the hand with the dropper on the client's forehead. ■ 4. Wipe the eyes with a tissue following administration of the drops.

2. The client should look up while the nurse instills the eyedrops. The client will need to keep both eyes open while the nurse administers the drug. If the client raises his eyebrows while the nurse's hand is positioned on the eyebrows, the movement of the forehead may cause the dropper to move and injure the eye. The client should gently blink his eyes after the eyedrops have been instilled. Using a tissue to wipe the eyes could remove some of the medication; excess fl uid can be removed with a cotton ball.

24. The nurse observes the client instill eyedrops. The client says, "I just try to hit the middle of my eyeball so the drops don't run out of my eye." The nurse explains to the client that this method may cause: ■ 1. Scleral staining. ■ 2. Corneal injury. ■ 3. Excessive lacrimation. ■ 4. Systemic drug absorption

2. The cornea is sensitive and can be injured by eyedrops falling onto it. Therefore, eyedrops should be instilled into the lower conjunctival sac of the eye to avoid the risk of corneal damage. The drops do not cause scleral staining or excessive lacrimation. Systemic absorption occurs when eyedrops enter the tear ducts

47. Which of the following statements indicates the client understands the expected course of Ménière's disease? ■ 1. "The disease process will gradually extend to the eyes." ■ 2. "Control of the episodes is usually possible, but a cure is not yet available." ■ 3. "Continued medication therapy will cure the disease." ■ 4. "Bilateral deafness is an inevitable outcome of the disease."

2. There is no cure for Ménière's disease, but the wide range of medical and surgical treatments allows for adequate control in many clients. The disease often worsens, but it does not spread to the eyes. The hearing loss is usually unilateral

22. Which of the following should the nurse provide as part of the information to prepare the client for tonometry? ■ 1. Oral pain medication will be given before the procedure. ■ 2. It is a painless procedure with no adverse effects. ■ 3. Blurred or double vision may occur after the procedure. ■ 4. Medication will be given to dilate the pupils before the procedure.

2. Tonometry, which measures intraocular pressure, is a simple, noninvasive, and painless procedure that requires no particular preparation or postprocedure care and carries no adverse effects. It is not necessary to dilate the pupils for tonometry.

A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival? Select all that apply. 1. Reflexes. 2. Bladder function. 3. Blood pressure. 4. Temperature. 5. Respirations.

3, 4, 5. The nurse should assess the client for spinal shock, which is the immediate response to spinal cord transection. Hypotension occurs and the body loses core temperature to environmental temperature. The nurse must treat the client immediately to manage hypotension and hypothermia. The nurse should also ensure that there is an adequate airway and respirations; there may be respiratory compromise due to intercostal muscle involvement. Once the client is stable, the nurse should conduct a complete neurologic check. The nurse should take all precautions to keep the client's head, neck, and spine position in straight alignment. If the client is conscious, the nurse should briefl y assess major refl exes, such as the Achilles, patellar, biceps, and triceps tendons, and sensation of the perineum for bladder function.

A health care provider has ordered carbidopa-levodopa (Sinemet) four times per day for a client with Parkinson's disease. The client states that he wants "to end it all now that the Parkinson's disease has progressed." What should the nurse do? Select all that apply. 1. Explain that the new prescription for Sinemet will treat his depression. 2. Encourage the client to discuss his feelings as the Sinemet is being administered. 3. Contact the health care provider before administering the Sinemet. 4. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. 5. Determine if the client is at risk for suicide.

3, 4, 5. The nurse should contact the health care provider before administering Sinemet because this medication can cause further symptoms of depression. Suicide threats in clients with chronic illness should be taken seriously. The nurse should also determine if the client is on an MAO inhibitor because concurrent use with Sinemet can cause a hypertensive crisis. Sinemet is not a treatment for depression. Having the client discuss his feelings is appropriate when the prescription is fi nalized.

83. Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? ■ 1. Limit fl uid intake to 1,000 mL/day. ■ 2. Insert an indwelling urinary catheter. ■ 3. Establish a regular voiding schedule. ■ 4. Administer prophylactic antibiotics, as ordered.

3. Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not infl uence urinary incontinence.

A client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines that the drug is effective when it achieves which of the following? 1. Induces sleep. 2. Stimulates the client's appetite. 3. Relieves muscular spasticity. 4. Reduces the urine bacterial count

3. Baclofen is a centrally acting skeletal muscle relaxant that helps relieve the muscle spasms common in MS. Drowsiness is an adverse effect, and driving should be avoided if the medication produces a sedative effect. Baclofen does not stimulate the appetite or reduce bacteria in the urine

80. Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will: ■ 1. Develop joint mobility. ■ 2. Develop muscle strength. ■ 3. Develop cognition. ■ 4. Develop mood elevation.

3. MS is a progressive, chronic neurologic disease characterized by patchy demyelination throughout the central nervous system. This interferes with the transmission of electrical impulses from one nerve cell to the next. MS affects speech, coordination, and vision, but not cognition. Care for the client with MS is directed toward maintaining joint mobility, preventing deformities, maintaining muscle strength, rehabilitation, preventing and treating depression, and providing client motivation

A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will: 1. Exhibit no further episodes of short-term memory loss. 2. Be able to return to his construction job in 3 weeks. 3. Actively participate in the rehabilitation process as appropriate. 4. Be emotionally stable and display pre-injury personality traits.

3. Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. Family members and signifi cant others will need long-term support to help them cope with the changes that have occurred in the client.

The nurse is reviewing the care plan of a client with Multiple Sclerosis. Which of the following nursing diagnoses should receive further validation? 1. Impaired mobility related to spasticity and fatigue. 2. Risk for falls related to muscle weakness and sensory loss. 3. Risk for seizures related to muscle tremors and loss of myelin. 4. Impaired skin integrity related bowel and bladder incontinence.

3. Symptoms that can occur with multiple sclerosis are muscle spasticity and weakness, fatigue, visual disturbances, hearing loss, and bowel and bladder incontinence. Seizures are not associated with myelin destruction.

What should the nurse do first when a client with a head injury begins to have clear drainage from his nose? 1. Compress the nares. 2. Tilt the head back. 3. Give the client tissues to collect the fluid. 4. Administer an antihistamine for postnasal drip

3. The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fl uid (CSF). The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage fl ow. It is inappropriate to tilt the head back, which would allow the fl uid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.

The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which of the following topics that the nurse plans to discuss is the most important? 1. Maintaining a balanced nutritional diet. 2. Enhancing the immune system. 3. Maintaining a safe environment. 4. Engaging in diversional activity.

3. The primary focus is on maintaining a safe environment because the client with Parkinson's disease usually has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking. This type of gait commonly causes the client to fall or to have trouble stopping. The client should maintain a balanced diet, enhance the immune system, and enjoy diversional activities; however, safety is the primary concern

113. The nurse has asked the nursing assistant to ambulate a client with Parkinson's disease. The nurse observes the nursing assistant pulling on the client's arms to get the client to walk forward. The nurse should: ■ 1. Have the nursing assistant keep a steady pull on the client to promote forward ambulation. ■ 2. Explain how to overcome a freezing gait by telling the client to march in place. ■ 3. Assist the nursing assistant with getting the client back in bed. ■ 4. Give the client a muscle relaxant.

3. The student has positioned the dropper and the client correctly to prevent injury to the client's eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.

3. The client has had a cataract removed. The nurse's discharge instructions should include which of the following? ■ 1. Keep the head aligned straight. ■ 2. Utilize bright lights in the home. ■ 3. Use an eye shield at night. ■ 4. Change the eye patch as needed.

3. Using an eye shield at night prevents rubbing the eye. The head should be turned to the side to scan the entire visual fi eld to compensate for impaired peripheral vision. Eye medications may initially cause sensitivity to bright light. The surgeon changes th

A client is being switched from levodopa (L-dopa) to carbidopa-levodopa (Sinemet). The nurse should monitor for which of the following possible complications during medication changes and dosage adjustment? 1. Euphoria. 2. Jaundice. 3. Vital sign fluctuation. 4. Signs and symptoms of diabetes

3. Vital signs should be monitored, especially during periods of adjustment. Changes, such as orthostatic hypotension, cardiac irregularities, palpitations, and light-headedness, should be reported immediately. The client may actually experience suicidal or paranoid ideation instead of euphoria. The nurse should monitor the client for elevated liver enzyme levels, such as lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and alkaline phosphatase, but the client should not be jaundiced. The client should not experience signs and symptoms of diabetes or a low serum glucose level, but the nurse should check the hemoglobin and hematocrit levels.

. During the period of spinal shock, the nurse should expect the client's bladder function to be which of the following? ■ 1. Spastic. ■ 2. Normal. ■ 3. Atonic. ■ 4. Uncontrolled.

3. During the period of spinal shock, the bladder is completely atonic and will continue to fi ll passively unless the client is catheterized. The bladder will not go into spasms or cause uncontrolled urination. Bladder function will not be normal during the period of spinal sho

60. The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. The nurse should: ■ 1. Allow the client to keep the eye drops at the bedside and use as prescribed on the bottle. ■ 2. Place the eye drops in the hospital medication drawer and administer as labeled on the bottle. ■ 3. Explain to the client that the physician will write an order for the eye drops to be used at the hospital. ■ 4. Ask the client's wife to assist the client in administering the eye drops while the client is in the hospital

3. In order to prevent medication errors, clients may not use medications they bring from home; the physician will order the eye drops as required. It is not safe to place the eye drops in the client's medication box or to permit the client to use them at the bedside. The nurse should ask the wife to take the eye drops home

79. A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is inappropriate? ■ 1. Eating a diet high in fi ber. 2. Setting a regular time for elimination. 3. Using an elevated toilet seat. 4. Limiting fl uid intake to 1,000 mL/day.

4. Limiting fl uid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fi ber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position

The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following? 1. The client's shoulders shrug against downward pressure of the examiner's hands. 2. The client's arm pulls up from a resting position against resistance. 3. The client's arm straightens out from a fl exed position against resistance. 4. The client's hand-grasp strength is equal.

4. The correct motor function test for C8 is a hand-grasp check. The motor function check for C4 to C5 is shoulders shrugging against downward pressure of the examiner's hands. The motor function check for C5 to C6 is an arm pulling up from a resting position against resistance. The motor function check for C7 is an arm straightening out from a fl exed position against resistance

The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses' notes of the chart for this client assessment? 1. "Has an intention tremor of the right hand." ■ 2. "Right-hand tremor worsens with purposeful acts." ■ 3. "Needs assistance with dressing and eating due to severe trembling and clumsiness." ■ 4. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."

4. The nurses' notes should be concise, objective, clearly stated, and relevant. This client trembles when she attempts voluntary actions, such as drinking a beverage or fastening clothing. This activity should be described exactly as it occurs so that others reading the note will have no doubt about the nurse's observation of the client's behavior. Identifying the "intentional" activity of daily living will help the interdisciplinary team individualize the client's plan of care. Clarifying what is meant by "worsening" with a purposeful act will facilitate the inter-rater reliability of the team. It is better to state what the client did than to give vague nursing orders in the nurses' notes

A new medication regimen is ordered for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken? 1. At bedtime. 2. All at one time. 3. Two hours before mealtime. 4. At the time scheduled.

4. While the client is hospitalized for adjustment of medication, it is essential that the medications be administered exactly at the scheduled time, for accurate evaluation of effectiveness. For example, levodopa-carbidopa (Sinemet) is taken in divided doses over the day, not all at one time, for optimum effectiveness.

25. Which of the following clinical manifestations should the nurse asessess when a client has acute angle-closure glaucoma? ■ 1. Gradual loss of central vision. ■ 2. Acute light sensitivity. ■ 3. Loss of color vision. ■ 4. Sudden eye pain.

4. Acute angle-closure glaucoma produces abrupt changes in the angle of the iris. Clinical manifestations include severe eye pain, colored halos around lights, and rapid vision loss. Gradual loss of central vision is associated with macular degeneration. The loss of color vision, or achromatopsia, is a rare symptom that occurs when a stroke damages the fusiform gyrus. It most often affects only half of the visual fi eld.

50. A client with Ménière's disease continues to have disabling attacks of vertigo and elects to have a labyrinthectomy. A priority nursing diagnosis for the client before surgery is: ■ 1. Defi cient diversional activity related to inability to participate secondary to vertigo. ■ 2. Risk for injury related to vertigo. ■ 3. Powerlessness related to inability to infl uence effects of disease process ■ 4. Social isolation related to hearing loss.

50. 2. The client's Risk for injury related to vertigo is the highest priority nursing diagnosis preoperatively. The client should be instructed how to manage attacks of vertigo safely. Defi cient diversional activity related to inability to participate secondary to vertigo is an appropriate nursing diagnosis, but it is not a priority. Powerlessness related to inability to infl uence effects of the disease process is a possible diagnosis, but more data are required before making such a diagnosis. Social isolation related to hearing loss is a possible diagnosis for the client after surgery. The client retains the ability to hear with Ménière's disease; however, total hearing loss is a possible complication of labyrinthectomy.

When planning to move a person with a possible spinal cord injury, the nurse should direct the team to: ■ 1. Limit movement of the arms by wrapping them next to the body. ■ 2. Move the person gently to help reduce pain. ■ 3. Immobilize the head and neck to prevent further injury. ■ 4. Cushion the back with pillows to ensure comfort.

3. The priority concern is to immobilize the head and neck to prevent further trauma when a fractured vertebra is unstable and easily displaced. Although wrapping and supporting the extremities is important, it does not take priority over immobilizing the head and neck. Pain usually is not a signifi cant consideration with this type of injury. Cushioning is contraindicated. The neck should be kept in a neutral position and immobilized. Flexion of the neck is avoided.

7. A short time after cataract surgery, the client complains of nausea. The nurse should fi rst: ■ 1. Instruct the client to take a few deep breaths until the nausea subsides. ■ 2. Explain that this is a common feeling that will pass quickly. ■ 3. Tell the client to call the nurse promptly if vomiting occurs. ■ 4. Medicate the client with an antiemetic, as ordered.

4. A prescribed antiemetic should be administered as soon as the client complains of nausea following a cataract extraction. Vomiting can increase intraocular pressure, which should be avoided after eye surgery because it can cause complications. Deep breathing is unlikely to relieve nausea. Postoperative nausea may be common; however, it doesn't necessarily pass quickly and can lead to vomiting. Telling the client to call only if vomiting occurs ignores the client's need for comfort and intervention to prevent complications.

48. The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo? ■ 1. "Place your head between your knees." ■ 2. "Concentrate on rhythmic deep breathing." ■ 3. "Close your eyes tightly." ■ 4. "Assume a reclining or fl at position."

4. The client needs to assume a safe and comfortable position during an attack, which may last several hours. The client's location when the attack occurs may dictate the most reasonable position. Ideally, the client should lie down immediately in a reclining or fl at position to control the vertigo. The danger of a serious fall is real. Placing the head between the knees will not help prevent a fall and is not practical because the attack may last several hours. Concentrating on breathing may be a useful distraction, but it will not help prevent a fall. Closing the eyes does not help prevent a fall.

. After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in his legs. He calls the nurse in excitement to report the leg movement. Which of the following responses by the nurse would be the most accurate? ■ 1. "These movements indicate that the damaged nerves are healing." ■ 2. "This is a good sign. Keep trying to move all the affected muscles." ■ 3. "The return of movement means that eventually you should be able to walk again." ■ 4. "The movements occur from muscle refl exes that can't be initiated or controlled by the brain."

4. The movements occur from muscle refl exes and cannot be initiated or controlled by the brain. After the period of spinal shock, the muscles gradually become spastic owing to an increased sensitivity of the lower motor neurons. It is an expected occurrence and does not indicate that healing is taking place or that the client will walk again. The movement is not voluntary and cannot be brought under voluntary control

49. The nurse should assess the client with Ménière's disease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Select all that apply. ■ 1. Antihistamines. ■ 2. Antiemetics. ■ 3. Diuretics. ■ 4. Non-steroidal anti-infl ammatory drugs (NSAIDs). ■ 5. Antipyretics

49. 1, 2, 3. Since the symptoms of Ménière's disease are associated with a change in the fl uid volume of the inner ear, a wide variety of medications may be used in an attempt to control the signs/symptoms of Ménière's disease, including antihistamines, antiemetics, tranquilizers, and diuretics. NSAIDs and antipyretics play no signifi - cant role in Ménière's disease management.

.You are preparing a nursing care plan for a client with an SCI for whom the nursing diagnoses of Impaired Physical Mobility and Toileting Self-Care Deficit have been identified. The client tells you, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing diagnosis takes priority? 1. Risk for Injury related to altered mobility 2. Imbalanced Nutrition: Less than Body Requirements 3. Impaired Individual Resilience related to spinal cord injury 4. Disturbed Body Image related to immobilization

Ans: 3 The client's statement indicates impaired individual resilience in adjusting to the limitations of the injury and the need for additional counseling, teaching, and support. The other three nursing diagnoses may be appropriate for a client with SCI but are not related to the client's statement.

.Before giving a beta-adrenergic blocking glaucoma agent, you would make additional assessments and notify the physician if the client makes which statement? 1. "My blood pressure runs a little high if I gain too much weight." 2. "Occasionally I have palpitations, but they pass very quickly." 3. "My joints feel stiff today, but that's just my arthritis." . "My pulse rate is a little low today because I take digoxin.

Ans: 4 All beta-adrenergic blockers are contraindicated in bradycardia. Alpha-adrenergic agents can cause tachycardia and hypertension. Carbonic anhydrase inhibitors should not be given to clients with rheumatoid arthritis who are taking high dosages of aspirin

.You are in charge of developing a standard plan of care in an Alzheimer disease care facility and are responsible for delegating and supervising resident care given by LPNs/LVNs and UAPs. Which activity is best to delegate to the LPN/LVN team leaders? 1. Checking for improvement in resident memory after medication therapy is initiated 2. Using the Mini-Mental State Examination to assess residents every 6 months 3. Assisting residents in using the toilet every 2 hours to decrease risk for urinary incontinence 4. Developing individualized activity plans after consulting with residents and family

Ans: 1 LPN/LVN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents' memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident. Assessing for changes in score on the Mini-Mental State Examination and developing the plan of care are RN responsibilities. Assisting residents with personal care and hygiene would be delegated to UAPs working at the long-term care facility.

20. The nurse should assess clients with chronic open-angle glaucoma (COAG) for: ■ 1. Eye pain. ■ 2. Excessive lacrimation. ■ 3. Colored light fl ashes. ■ 4. Decreasing peripheral vision

4. Although COAG is usually asymptomatic in the early stages, peripheral vision gradually decreases as the disorder progresses. Eye pain is not a feature of COAG but is common in clients with angle-closure glaucoma. Excessive lacrimation is not a symptom of COAG; it may indicate a blocked tear duct. Flashes of light is a common symptom of retinal detachment.

5. A client tells the nurse his vision is blurred and hazy throughout the entire day. The nurse should recommend that the client do which of the following? ■ 1. Purchase a pair of magnifying glasses. ■ 2. Wear glasses with tinted lenses. ■ 3. Schedule an appointment with an optician. ■ 4. Schedule an appointment with an ophthalmologist

4. An ophthalmologist is a physician who specializes in the treatment of disorders of the eye, and the nurse should advise the client to see a physician. An optician makes glasses and it is not known at this point what the best treatment for the client is. Magnifying glasses, or glasses with tinted lenses, do not correct hazy or blurred vision. If glasses are needed to correct refractive errors, they should be prescription glasses.

When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? 1. Encouraging the client to speak slowly. 2. Encouraging the client to speak distinctly. 3. Asking the client to repeat indistinguishable words. 4. Asking the client to speak louder when tired.

4. Asking a client to speak louder even when tired may aggravate the problem. Asking the client to speak slowly and distinctly and to repeat hard-tounderstand words helps the client to communicate effectively

Which goal is the most realistic and appropriate for a client diagnosed with Parkinson's disease? 1. To cure the disease. 2. To stop progression of the disease. 3. To begin preparations for terminal care. 4. To maintain optimal body function

4. Helping the client function at his or her best is most appropriate and realistic. There is no known cure for Parkinson's disease. Parkinson's disease progresses in severity, and there is no known way to stop its progression. Many clients live for years with the disease, however, and it would not be appropriate to start planning terminal care at this time.

While visiting a client with multiple sclerosis, the community health nurse observes that the client looks untidy and sad. The client suddenly says, "I can't even fi nd the strength to comb my hair," and bursts into tears. Which of the following responses by the nurse is best? ■ 1. "It must be frustrating not to be able to care for yourself." ■ 2. "How many days have you been unable to comb your hair?" ■ 3. "Why hasn't your husband been helping you?" ■ 4. "Tell me more about how you're feeling."

4. By asking the client to tell more about how she is feeling, the nurse is not making any assumptions about what is troubling the client. The nurse should acknowledge the client's feelings and encourage her to discuss them. Saying that this situation must be frustrating involves assumptions by the nurse about why the client is crying and is not a therapeutic response. Asking how long the client has been unable to comb her hair takes the focus off her feelings and inhibits therapeutic communication. Inquiring why the client's husband hasn't helped insinuates that the husband is not helping enough, which is inappropriate, takes the focus off the client's feelings, and inhibits therapeutic communication

38. The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following? ■ 1. Contact the client's audiologist. ■ 2. Cleanse the hearing aid ear mold in normal saline. ■ 3. Irrigate the ear canal. ■ 4. Check the hearing aid's placemen

4. Inadequate amplifi cation can occur when a hearing aid is not placed properly. The certifi ed audiologist is licensed to dispense hearing aids. The ear mold is the only part of the hearing aid that may be washed frequently; it should be washed daily with soap and water. Irrigation of the ear canal is done to remove impacted cerumen or a foreign body.

Which of the following should the nurse use as the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury? ■ 1. Homans' sign. ■ 2. Pain. ■ 3. Tenderness. ■ 4. Leg girth.

4. Measuring the leg girth is the most appropriate method because the usual signs, such as a positive Homans' sign, pain, and tenderness, are not present. Other means of assessing for deep vein thrombosis in a client with a spinal cord injury are through a Doppler examination and impedance plethysmography.

12. After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which of the following postoperative complications? ■ 1. Detached retina. ■ 2. Prolapse of the iris. ■ 3. Extracapsular erosion. ■ 4. Intraocular hemorrhage.

4. Sudden, sharp pain after eye surgery should suggest to the nurse that the client may be experiencing intraocular hemorrhage. The physician should be notifi ed promptly. Detached retina and prolapse of the iris are usually painless. Extracapsular erosion is not characterized by sharp pain.

.A client with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may delegate which actions to an LPN/LVN? (Select all that apply.) 1. Checking the client's skin for pressure from the device 2. Assessing the client's neurologic status for changes 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 5. Developing the nursing plan of care for the client

Ans: 1, 3, 4 Checking and observing for signs of pressure or infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Neurologic examination and care plan development require additional education and skill appropriate to the professional RN.

.All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson disease who has been referred to your home health agency. Which activities will you delegate to the UAP? (Select all that apply.) 1. Checking for orthostatic changes in pulse and blood pressure 2. Assessing for improvement in tremor after levodopa (l-dopa [Larodopa]) is given 3. Reminding the client to allow adequate time for meals 4. Monitoring for signs of toxic reactions to anti-Parkinson medications 5. Assisting the client with prescribed strengthening exercises 6. Adapting the client's preferred activities to his level of function

Ans: 1, 3, 5 UAP education and scope of practice include taking pulse and blood pressure measurements. In addition, UAPs can reinforce previous teaching or skills taught by the RN or personnel in other disciplines, such as speech or physical therapists. Evaluating client response to medications and developing and individualizing the plan of care require RN-level education and scope of practice.

.You are mentoring a student nurse in the intensive care unit (ICU) while caring for a client with meningococcal meningitis. Which action by the student requires that you intervene most rapidly? 1. Entering the room without putting on a mask and gown 2. Instructing the family that visits are restricted to 10 minutes 3. Giving the client a warm blanket when he says he feels cold 4. Checking the client's pupil response to light every 30 minutes

Ans: 1 Meningococcal meningitis is spread through contact with respiratory secretions, so use of a mask and gown is required to prevent transmission of the infection to staff members or other clients. The other actions may not be appropriate but do not require intervention as rapidly. The presence of a family member at the bedside may decrease client confusion and agitation. Clients with hyperthermia frequently report feeling chilled, but warming the client is not an appropriate intervention. Checking the pupils' response to light is appropriate but is not needed every 30 minutes and is uncomfortable for a client with photophobia

8. Which of the following is a potential complication following cataract surgery? Select all that apply. ■ 1. Acute bacterial endophthalmitis. ■ 2. Retrobulbar hemorrhage. ■ 3. Rupture of the posterior capsule. ■ 4. Suprachoroidal hemorrhage. ■ 5. Vision loss.

. 1, 5. Acute bacterial endophthalmitis can occur in about 1 out of 1,000 cases. Organisms that are typically involved include Staphylococcus epidermidis, S. aureus, and Pseudomonas and Proteus species. Vision loss is one result of acute bacterial infection. In addition, vision loss can be the result of malposition of the intraocular lens implant or opacifi cation of the posterior capsule. Retrobulbar hemorrhage is a complication that may occur right before surgery and is a result of retrobulbar infi ltration of anesthetic agents. Rupture of the posterior capsule and suprachoroidal hemorrhage are both complications that can result during surgery

As a fi rst step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which of the following statements by the client indicates she understands her current ability? ■ 1. "I won't be able to have sexual intercourse until the urinary catheter is removed." ■ 2. "I can participate in sexual activity but might not experience orgasm." ■ 3. "I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay." ■ 4. "I should be able to participate in sexual activity, but I will be infertile."

2. The woman with spinal cord injury can participate in sexual activity but might not experience orgasm. Cessation in the nerve pathway may occur in spinal cord injury, but this does not negate the client's mental and emotional needs to creatively participate with her partner in a sexual relationship and to reach orgasm. An indwelling urinary catheter may be left in place during intercourse and need not be removed because the indwelling urinary catheter is placed in the urethra, which is not the channel used for sexual intercourse. There are no contraindications, such as hypertension, to sexual activity in a woman with spinal cord injury. Sexual intercourse is allowed, and hypertension should be manageable. Because a spinal cord injury does not affect fertility, the client should have access to family planning information so that an unplanned pregnancy can be avoided.

The client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. Which of the following responses by the nurse would provide the most accurate information? ■ 1. "Excessive intake of dairy products makes constipation more common." ■ 2. "Immobility increases calcium absorption from the intestine." ■ 3. "Lack of weight bearing causes demineralization of the long bones." ■ 4. "Dairy products likely will contribute to weight gain."

3. Long-bone demineralization is a serious consequence of the loss of weight bearing. An excessive calcium load is brought to the kidneys, and precipitation may occur, predisposing to stone formation. Excessive intake of dairy products may promote constipation. However, this is not the most accurate reason for decreasing calcium intake. Immobility does not increase calcium absorption from the intestine. Dairy products do not necessarily contribute to weight gain.

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which of the following responses by the nurse conveys the best understanding of the client's behavior? ■ 1. "Be patient. It takes time to adjust to such a massive loss." ■ 2. "Talking about the past is a form of denial. We have to help you focus on today." ■ 3. "Reviewing your losses is a way to help you work through your grief and loss." ■ 4. "It's a simple escape mechanism to go back and live again in happier times."

3. Spinal cord injury represents a physical loss; grief is the normal response to this loss. Working through grief entails reviewing memories and eventually letting go of them. The process may take as long as 2 years. Telling the client to be patient and that adjustment takes time is a clichéd type of response, one that is not empathetic or responsive to the client's needs. Telling the client to focus on today does not allow time for the grief process, which is necessary for the client to work through and adjust to the loss. The client is not escaping but is reminiscing on what is lost, to work through the grieving process.

141. To reduce the risk of pressure ulcer formation, which of the following activities should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury? ■ 1. Bathe daily. ■ 2. Eat a high-carbohydrate diet. ■ 3. Shift your weight every 15 minutes. ■ 4. Move from the bed to the wheelchair every 2 hours

3. The client who is wheelchair-bound with a spinal cord injury should be taught to make small weight shifts, lifting off the sacral area every 15 minutes. This decreases the risk of pressure ulcer formation. Bathing daily promotes skin cleanliness, but by itself will not prevent pressure ulcer formation. Eating a well-balanced diet that includes proteins and carbohydrates promotes good skin integrity. Moving from the bed to the wheelchair every 2 hours is not desirable because the client should not spend excessive amounts of time in bed. Pressure sores can develop in less than 2 hours

.You are helping a client with an SCI to establish a bladder retraining program. Which strategies may stimulate the client to void? (Select all that apply.) 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 3. Initiating intermittent straight catheterization 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle

Ans: 1, 2, 4, 5 All of the strategies except straight catheterization may stimulate voiding in clients with an SCI. Intermittent bladder catheterization can be used to empty the client's bladder, but it will not stimulate voiding.