NURS 120 ATI Targeted Neurosensory + Musculoskeletal (2)

A nurse is caring for a client who has a retinal detachment. Which of the following reports about the affected eye should the nurse report?

Flashes of bright light.

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of instructions?

"i should call my doctor if my vision gets worse" "I should call my doctor if I experience a decrease in my vision."

A nurse in the emergency department is caring for a client after suddenly losing consciousness and falling in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer?

"tissue plasminogen activator" Recombiant tissue plasminogen activator.

A nurse is caring for a client who was admitted for status epilepticus and is on seizure precautions. Which of the following actions should the nurse plan to take?

Establish IV access.

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority?

Maintain a PaCO2 of approximately 35 mm Hg.

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?

Monitor capillary refill at least every 4 hr.

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?

Monitor pulse oximetry findings.

A nurse is assessing a client who has a possible head injury following a motor vehicle crash. The nurse should recognize that which of the following findings indicates increasing intercranial pressure?

Restlessness.

A nurse is caring for a client who has spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?

Stroke the client's inner thigh.

A nurse is teaching a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the client's medication teaching plan?

Take medications at consistent time each day to maintain therapeutic blood levels.

nurse performing a pain assessment for a client who is postoperative. which of the following findings should the nurse use to determine the severity of the clients pain

client's report of pain on a pain scale

A nurse is providing teaching for a client who is postoperative following a right hip arthroplasty. Which of the following indicates the position the nurse should teach the client to take when sitting?

image of pt sitting upright with feet flat on the floor Sitting upright with feet flat on floor.

A nurse is providing teaching a new prescription for cabidopa-levodopa for a client who has Parkinson's disease. Which of the following client statements indicates an understanding of the teaching?

"I should expect my urine to be a darker color."

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?

Administer an (oral) dose of gabapentin to the client. - admin a nonopioid medication to help minimize phantom limb pain - this is an oral antiepileptic medication that is effective for treating sharp, burning, phantom limb pain

A nurse in the emergency department is assessing a client who has myasthenia gravis. The client reports recent increasing muscle weakness and the nurse suspects the client is experiencing a myasthenic crisis. Which of the following actions is the nurse's priority?

Assist with the Tensilon test.

A nurse is caring for a client who has a full arm cast and reports pain of 8 on a scale from 0 to 10 that is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

Check the circulation of the affected extremity.

A nurse is caring for a client in balanced suspension who reports intermittent muscle spasms. Which of the following actions should the nurse take first?

Check the position of the weights and ropes.

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include?

Ensure the client lies flat for 4 to 8 hr.

A nurse working in the emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images indicates a comminuted fracture?

First image: http://imgur.com/GssMWM7 - the one looking straight at the bone - with bunch of bone fragments in between top and bottom parts of bone - with dark black area to right of middle

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

Intention tremors. - clients who have MS are at risk for motor dysfunction, with intention tremors, poor coordination, and loss of balance - pt with MS have hyperactive deep tendon reflexes

A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect?

Ulnar deviation.

a nurse is teaching an AP about care of a client following a total hip arthroplasty. which of the following instructions should the nurse include

place an abductor pillow between the client's legs when turning the client

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include?

Move head slowly to decrease vertigo.

A nurse in the emergency department is assessing a client who reports sudden, severe eye pain with blurred vision The provider determines the client has primary angle-closure glaucoma. Which of the following medications should the nurse administer?

Osmotic diuretics via IV bolus.

A nurse is providing teaching for a client who is prescribed alendronate for osteoporosis. Which of the following information should the nurse include in the teaching?

Remain upright for 30 min after taking this medication.

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following findings should the nurse report to the provider?

Clear drainage from the nose.

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect? (Select all that apply.)

Crepititus with joint movement Decreased range of motion of the affected joint. Joint pain that resolves with rest.

A nurse is caring for a client who is 8 hr postoperative following a craniotomy. Which of the following actions should the nurse take?

Report wound drainage greater than 50ml/ 8 hr.

A nurse is providing teaching for a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements by the family indicates an understanding of the teaching?

"The medications that treat Alzheimer's disease can help delay cognitive changes."

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level C5. The client report a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/ 110 mm Hg. Which of the following actions should the nurse take first?

Elevate the head of the client's bed.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

Impulsive behavior.

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt, the nurse should take which of the following actions?

Remind the client to look consciously at both sides of his meal tray.