ATI - Musculoskeletal/Neuro
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 prority?
Assist with Tensilon test
When caring for a client who has multiple sclerosis, the nurse should recognize that this disorder is characterized by:
Remissions and exacerbations
One hour after application of a cast for an ulnar fracture, a client reports a pain level of 8 on a scale from 0-10 that is unrelieved by analgesics and the application of a cold pack. The client's fingers are pale and numb. Based on the client's report which of the following actions should the nurse take first?
Report the findings to the primary care provider
A nurse is caring for a client who is 8 hours postoperative following a craniotomy. Which of the following actions should the nurse take?
Report wound drainage greater than 50 mL/8hrs
A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure
Restlessness
A nurse is providing teaching for a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?
The nurse should teach the client to sit with the hips at a 90 degree angle or less with the knees slightly lower than the hips to avoid hip dislocation.
A nurse is teaching a client who has osteoporosis and a new script for alendronate. Which of the following information should the nurse include in the teaching?
This medication should be taken before breakfast and in an upright position maintained for 30 minutes
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 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"
A nurse is teaching a client who has parkinson;s disease about taking carbidopa-levodopa. 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 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 drugs used to treat Alzheimer's disease can help delay cognitive changes"
A nurse 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.
A. Injury that cause the bone to fragment into several pieces.
A Nurse is caring for a client who is 72 hours postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?
Administer an oral does of gabapentin to the client
A nurse is caring for a client who has a full arm cast and reports pain of an 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 skeletal traction 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 caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?
Clear drainage from the nose
A nurse is performing a pain assessment on a postoperative client. Which of the following should the nurse use to determine the severity of the client's pain?
Client's report of pain on a standardized pain scale
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)
Crepitus with joint movement Decreased range of motion of the affected joint Joint pain that resolves with rest
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 hours
A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take?
Establish IV access
A nurse is caring for a client who is postoperative following a craniotomy. Which of the following interventions is the priority action for the nurse to take?
Elevate the head of the bed 30 degrees
A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level CS. The client reports 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 has multiple sclerosis. Which of the following findings should the nurse expect?
Intention tremors
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 35mm 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 hours
A nurse is caring for a client who has advancing amyotrophc lateral sclerosis. Which of the following interventions is the nurse's priority?
Monitor pulse oximetry findings
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 is caring for a client who is admitted with ascending guillain-barre syndrome. The nurse should give priority to which of the following assessment findings?
Presence of adventitious breath sounds
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
A nurse is caring for a client who has a 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 planning to teach a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the clients medication teaching plan?
Take medications at a consistent time each day to maintain therapeutic blood levels
A nurse is teaching an assistive personnel about care of a client who has had a total hip arthroplasty. Which of the following instructions should the nurse include?
place an abductor pillow between the clients legs when turning the client
A nurse is caring for a client who has a retinal detachment. Which of the following reports about the affected eye should the nurse expect?
Flashes of bright light
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 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
