AD2E4

MS- S/s

-Optic neuritis-Nystagmus resulting from internuclear ophthalmoplegia-Lhermitte sign (electrical sensation that extends down the back and legs with neck flexion)-Impaired coordination-Fatigue

A nurse is caring for a client following a below-the-elbow amputation. Which of the following actions should the nurse take? (Select all that apply) A. Encourage dependent position of the residual limb B. Inspect for presence and amount of drainage C. Implement shrinkage intervention of the residual limb D. Wrap the residua limb in a circular manner using gauze E. Asses for feelings of body image changes

A,B,C,E

A nurse is assessing an older adult client who has arteriosclerosis and is scheduled for a possible right lower extremity amputation. Which of the following are expected findings in the affected extremity? (Select all that apply) A. Skin cool to touch from mid-calf to the toes B. Lower leg appearing dusky when client is sitting C. Palpable pounding pedal pulses D. Lack of hair on lower leg E. Blackened areas on several toes

A,B,D,E

. A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? (Select all that apply.) A. Implement seizure precautions. B. Perform neurological checks four times a day. C. Administer morphine for the report of neck and generalized pain. D. Turn off room lights and television. E. Monitor for impaired extraocular movements. F. Encourage the client to cough frequently.

A. Implement seizure precautions.D. Turn off room lights and television.E. Monitor for impaired extraocular movements.

2. A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (Select all that apply.) A. Place client in supine position. B. Flex client's hip and knee. C. Place hands behind the client's neck. D. Bend client's head toward chest. E. Straighten the client's flexed leg at the knee.

A. Place client in supine position.C. Place hands behind the client's neck.D. Bend client's head toward chest.

A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (select all that apply) A. Provide privacy B. Ease the client to the floor is standing C. Move furniture away from the client D. Looses the client's clothing E. Protect the client's head with padding F. Restrain the client

A. Provide privacyB. Ease the client to the floor if standingC. Move furniture away from the clientD. Loosen the client's clothingE. Protect the client's head with padding

A nurse is answering a call light for a client who reports that their broken arm suddenly hurts. Upon inspecting the arm in the splint, the nurse notes a major increase in swelling. The clients capillary refill is about 5 seconds long. The nurse knows this client is experiencing compartment syndrome and prepares the client for which of the folllwing?A) Fasciotomy B) Reduction of the bones C) Application of a splint D) No treatment

ANS: A

A patient has just been admitted into the ER with a femur fracture. The nurse knows which device will most likely be used for this patient? A) Skeletal traction B) Bucks Traction C) Plaster cast D) Splint

ANS: A

Which is not a guideline for avoiding hip dislocation after replacement surgery. A) Keep the knees apart at all times. B) Never cross the legs when seated. C) Put a pillow between the legs when sleeping. D) The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes.

ANS: A

MS- Risk Factors

20-40Women Nothern European Temperate areas of the world Genetics Tobacco use

A nurse is educating a client on prevention of compartment syndrome. What does the nurse need to include? A) Elevation of extremity B) Applying ice C) Avoid heat D) Avoid Compression wrapping

ANS: D

CVA- risk factors for women

3rd leading cause of death in the US for women-Migraine w/ aura-Metabolic syn (esp with GDM)-Tobacco use-Increasing age-Hormonal changes (Oral contraception, pregnancy -preeclampsia/eclampsia, pregnancy induced HTN, and GGM)-Psychosocial stress

Which of the following would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? A) Numbness B) Atrophy of the thenar prominence C) No tingling D) Hard, painless Bouchard nodes

A

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority? A) Assessing the extremity for neurovascular integrity B) Keeping the client from sliding to the foot of the bed C) Ensuring that the weights hang free at all times D) Keeping the ropes over the center of the pulley

ANS: A) Assessing the extremity for neurovascular integrityRational:Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.

A client has a left ulnar fracture. Which of the following findings would concern the nurse?A) Pulses are +1 bilaterally B) No open break in the skin C) Swelling at the break site D) Capillary refill of about 5 seconds.

ANS: D) Capillary refill of about 5 seconds.

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for? A) Hypovolemia B) Atelectasis C) Urinary tract infection D) Pulmonary embolism

ANS: Pulmonary embolism

A nurse is presenting information to a group of clients at a health fair about measures to reduce the risk of amputation. Which of the following information should the nurse provide? (Select all that apply) A. Encourage clients who smoke to consider smoking cessation programs B. Encourage clients who have diabetes mellitus to maintain blood glucose within the expected reference range C. Instruct clients to unplug electrical electrical equipment when performing repairs D. Encourage clients who have vascular disease to maintain good foot care E. Advise clients to wait 2h after taking pain meds before driving

Answer: A/B/C/D

A nurse is planning a plan of care to prevent a client from developing flexion contractures following a below-the-knee amputation 24h ago. Which of the following actions should the nurse include in the plan of care? A. Limit any type of exercise to the residual limb for the first 48h after surgery B. Position the client prone several times each day C. Wrap the stump in a figure-eight pattern D. Encourage sitting in a chair during the day

B

5. A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Monitor for bradycardia. B Provide an emesis basin at the bedside C., Administer antipyretic medication. D Perform a skin assessment. E. Keep the head of the bed flat.

B Provide an emesis basin at the bedside.C., Administer antipyretic medication.D Perform a skin assessment.

1. A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A Administer antibiotics. B. Implement droplet precautions. C. Initiate IV access. D. Decrease bright lights.

B. Implement droplet precautions.

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (select all that apply) A. Monitor for bradycardia B. Provide an emesis basin at the bedside C. Administer antipyretic medication D. Perform a skin assessment E. Keep the head of the bed flat

B. Provide an emesis basin at bedsideC. Administer antipyretic medicationD. Perform a skin assessment

4. A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A. The vaccine is indicated to reduce the risk of respiratory infection. B. The vaccine is administered in a series of four doses. C. The vaccine is recommended for adolescents before starting college. D. The vaccine is initially given at 2 months of age.

C. The vaccine is recommended for adolescents before starting college.

A nurse is caring for a client who has an above-the-knee amputation. The client reports a sharp, stabbing kind of phantom pain. Which of the following actions should the nurse take? A. Facilitate counseling interventions B. Encourage use of cold therapy C. Question whether the pain is real D. Administer an anti-epileptic medication

D

PD- motor indications

Decreased arm swing on affected side Drags one or both feet Masked face (less expressive) Rapid or "propulsive" gait Progressively faster steps that turns into running; May precipitate falling forward Hypophonia (soft speech) Micrographia (small handwriting) "Freezing" of gait, transient inability to perform active movements Freezing most frequently affects the legs but can also affect eye lip opening, speaking and writing

MS-diagnostic criteria

Definitive dx requires evidence of demyelinating disease consisting of 2 attacks that occurred at different points in time Symptoms should last at least 24 hours in the absence of a fever and affect two diff. areas of the CNS (brain, spinal cord, or optic nerve).

PD:Non-motor signs

Dysphagia Drooling- Accumulation of saliva in the mouth due to less frequently swallowing Decreased blinking (low levels of dopamine) Seborrhea- Increased in male patients Myerson's sign Repetitive tapping over the bridge of the nose may cause blinking

PDDX is made by clinical eval and consist of a combo of 6 cardinal features: TRAP + either tremor at rest or bradykinesia

The diagnosis is based on 4 cardinal features: Tremor Rigidity Akinesia/ bradykinesia Postural instability associated with flexed posture Symptoms will not appear until 70% of basal ganglion has been destroyed