ATI Neuro
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 -Involvement of smaller joints of the body, low-decreased fever -Spongy tissue over the joints -Joint pain that resolves with rest
125 1. Crepitus with joint movement is correct. Osteoarthritis is a degenerative joint disease. Crepitus, a grating sound, is an expected finding with osteoarthritis as loosened bone and cartilage move around in the fluid inside the joint. 2. Decreased range of motion of the affected joint is correct. Decreased range of motion is an expected finding of osteoarthritis because the client's pain limits movement. 3. Involvement of smaller joints of the body is incorrect. Osteoarthritis affects larger joints, such as the hips and knees. Osteoarthritis does not cause systemic manifestations. Rheumatoid arthritis causes many systemic manifestations, including low-grade fever, weakness, anorexia, and paresthesias. 4. Spongy tissue over the joints is incorrect. Spongy joint tissue is an expected finding of rheumatoid arthritis, which is an inflammatory disease, not a degenerative disease. 5. Joint pain that resolves with rest is correct. Clients who have osteoarthritis have increased pain with activity and decreased pain with rest.
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? -crossing the affected leg over the center of the body -sit with the hips at a 90° angle with the knees slightly lower than the hips -sitting with the knees higher than the hips -leaning forward over the knees
2. The nurse should teach the client to sit with the hips at a 90° angle or less with the knees slightly lower than the hips to avoid hip dislocation. The nurse should instruct the client to avoid crossing the affected leg over the center of the body to avoid hip dislocation. avoid sitting with the knees higher than the hips to avoid hip dislocation. avoid leaning forward over the knees to avoid hip dislocation.
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? Administer additional pain medication. Check the circulation of the affected extremity. Document the findings. Reposition the affected extremity.
Check the circulation of the affected extremity. The GREATEST risk to the client is neuromuscular injury resulting from compartment syndrome. The FIRST action the nurse should take is to check for impaired circulation of the affected extremity. The nurse might need to reposition the client's arm to promote venous return and comfort. or The nurse should document the findings to maintain professional standards. or The nurse might need to administer additional pain medication to control the client's pain. However, there is another action the nurse should take first.
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? Reposition the client. Provide distraction. Administer a muscle relaxant. Check the position of the weights and ropes.
Check the position of the weights and ropes. The first action the nurse should take using the nursing process is to assess the client. The nurse should first check the position of the weights and ropes to determine the cause of the muscle spasms. The weights might be too heavy, or the nurse might need to realign the client. The nurse should reposition the client to realign him and try to relieve his muscle spasms. However, there is another action the nurse should take first. The nurse should administer a muscle relaxant to minimize the client's muscle spasms. However, there is another action the nurse should take first. The nurse should provide sensory stimulation to help the client keep his focus away from the pain of the spasms. However, there is another action the nurse should take first.
A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level C5. 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? Administer hydralazine via IV bolus. Loosen the client's clothing. Empty the client's bladder. Elevate the head of the client's bed.
Elevate the head of the client's bed. These assessment findings indicate the client is at greatest risk for autonomic dysreflexia and possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension. The nurse should administer hydralazine, a potent vasodilator, to lower the client's blood pressure. The nurse should loosen the client's clothing because body temperature and tactile stimulation are triggers of autonomic dysreflexia. The nurse should empty the client's bladder because a full bladder or a fecal impaction is a trigger of autonomic dysreflexia. However, there is another action the nurse should take first.
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? Photophobia Complete blindness Flashes of bright light Pain
Flashes of bright light During retinal detachment, the client can experience flashes of bright light or floating dark spots in the affected eye as the retinal layers SEPARATE. A retinal detachment does not typically cause photophobia. More likely, clients who have this disorder will report a sensation of a curtain or a shade blocking the vision of one eye. He or she can have some visual field loss in the area of the detachment but should not have complete blindness. Clients who have a retinal detachment should not have pain, because there are NO pain fibers in the retina.
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 I experience a decrease in my vision." "I may take aspirin for eye discomfort following the surgery." "I can blow my nose to clear out any drainage." "I can lift objects up to 20 pounds."
I should call my doctor if I experience a decrease in my vision." The client should report changes in vision immediately because there should be an improvement in vision after the surgery. The client should avoid aspirin because it can cause bleeding in the eye. avoid blowing his nose because it can increase intraocular pressure. avoid blowing his nose because it can increase intraocular pressure.
A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect? Aphasia Right-sided neglect Impulsive behavior Inability to read
Impulsive behavior The nurse should expect the client who had a right hemispheric stroke to demonstrate impulsive behavior, poor judgment, and lack of awareness of neurologic deficits. Clients who had a right hemispheric stroke are likely to have neurologic deficits on the left side of the body, not the right side. The nurse should expect the client to be unaware of and unable to move the left side of the body. Aphasia for Clients who had a left hemispheric stroke are likely to have aphasia. Clients who had a left hemispheric stroke are likely to have difficulty reading due to the inability to discriminate different letters and words.
A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority? -Provide for frequent rest periods throughout the day. -Medicate for pain on a regular schedule. -Monitor pulse oximetry findings. -Administer baclofen for spasticity.
Monitor pulse oximetry findings. The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor oxygen saturation to identify respiratory compromise as soon as possible. The nurse should provide for frequent rest periods throughout the day because the client's fatigue will increase as the disease progresses. The nurse should administer pain medication on a regular schedule to keep the client's pain level under control. The nurse should give baclofen to manage spasticity that can interfere with self-care. However, this is not the priority intervention.
A nurse is developing a teaching plan for a client who has Ménière's disease. Which of the following instructions should the nurse include? Move head slowly to decrease vertigo. Apply warm packs to the affected ear during acute attacks. Increase intake of foods and fluids high in salt. Administer corticosteroids during acute attacks.
Move head slowly to decrease vertigo. The client should use slow head movements decrease the stimulation of vertigo. Applying warm packs to the affected ear does not relieve the manifestations of Ménière's disease. Helpful interventions include drinking PLENTY of water, decreasing salt intake, and not smoking. PT should avoid consuming foods and fluids that have a HIGH Sodium content because they cause fluid retention, which exacerbates the manifestations of Ménière's disease. Taking corticosteroids will not relieve the manifestations of Ménière's disease and can actually worsen them because these medications cause fluid retention. The client should take an AntiHistamine, such as meclizine, to minimize or stop the attack.
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? Recombinant tissue plasminogen activator Recombinant factor VIII Nitroglycerin Lidocaine
Recombinant tissue plasminogen activator Recombinant tissue plasminogen activator is a thrombolytic administered to DISSOlve the blood clot that caused the stroke. Recombinant factor VIII helps manage the manifestations of hemophilia. Nitroglycerin is a coronary and venous vasodilator that treats angina. Lidocaine is an antidysrhythmic agent that treats ventricular dysrhythmias.
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 intracranial pressure? Restlessness Dizziness Hypotension Fever
Restlessness Behavioral changes, such as restlessness or irritability, are early manifestations of increased intracranial pressure. Although dizziness might be present after head trauma, it is not a manifestation of increased intracranial pressure. Although hypotension might be present after head trauma, especially if the client is experiencing hypovolemic or neurogenic shock, it is not a manifestation of increased intracranial pressure. Cushing's triad of hypertension, bradycardia, and a widening pulse pressure is a late manifestation of increased intracranial pressure. Although a client who has head trauma can develop fever, it is either in response to infection or due to hypothalamic damage, not due to increased intracranial pressure.
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? an image of a greenstick fracture, in which the injury causes the bone to fracture on one side and bend on the other side. an image of an open fracture, in which there is damage involving the skin or mucous membranes. an image of a spiral fracture, in which the fracture twists around the shaft of the bone.
an image of a comminuted fracture, in which the injury causes the bone to fragment into several pieces. A comminuted fracture is a break or splinter of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma such as in vehicular accidents.
A nurse is providing teaching regarding a new prescription for carbidopa-levodopa for a client who has Parkinson's disease. Which of the following client statements indicates an understanding of the teaching? "I should expect a slight increase in my blood pressure while taking this medication." "I should take my medication with a high-protein food." "I should expect my urine to be a darker color." "I will expect it to take up to a week for this medication to work."
"I should expect my urine to be a darker color." Saliva, urine, and sweat can darken in color during carbidopa-levodopa therapy. This is a harmless adverse effect. 1. Orthostatic hypotension is an adverse effect of carbidopa-levodopa. 2. High-protein foods can reduce the absorption of carbidopa-levodopa and the transportation of the medication to the brain. 4. The nurse should inform the client that it can take several months for this medication to take effect.
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? Glasgow Coma Scale score of 15 Intracranial pressure reading of 15 mm Hg Ecchymosis at base of skull Clear drainage from nose
*Clear drainage from nose Clear drainage from the nose indicates cerebral spinal fluid is leaking from the skull fracture. This places the client at risk for meningeal infection because micro-organisms have access to the cranium through the nose and the tear in the dura. The nurse should report this finding to the provider. A Glasgow Coma Scale score of 15 indicates intact neurologic functioning. An intracranial pressure reading of 15 mm Hg is at the upper limit of the expected reference range. A client who has a basilar skull fracture is likely to have ecchymosis at the base of the skull from a contusion.
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? -Remind the client that the limb has been removed. -Change the dressing on the client's residual limb. -Administer an oral dose of gabapentin to the client. -Elevate the client's residual limb above heart level.
Administer an oral dose of gabapentin to the client. The nurse should administer a nonopioid medication to the client experiencing phantom limb pain. Gabapentin is an antiepileptic medication and is effective for treatment of phantom limb pain. It is not therapeutic for the nurse to remind the client that the limb is gone because it does not address the client's pain. Changing the dressing on the client's residual limb does not address the client's pain. Changing the dressing on the client's residual limb does not address the client's pain.
A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include? Apply a pressure dressing to the site for 12 hr. Restrict the client's fluid intake for 24 hr. Ensure the client lies flat for 4 to 8 hr. Administer pain medication every 3 to 4 hr.
Ensure the client lies flat for 4 to 8 hr. The client should lie flat for 4 to 8 hr to prevent cerebrospinal fluid leakage from the puncture site.
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? Assess hourly for a spike in blood pressure. Maintain the client on bed rest. Keep a padded tongue blade at the bedside. Establish IV access.
Establish IV access. The nurse should plan to establish IV access with a large-bore catheter and administer 0.9% sodium chloride if seizures are imminent. If the client is stable, the nurse should initiate a saline lock. The nurse should check the client's vital signs and perform neurological checks after a seizure. However, a change in blood pressure does not correlate with an increased incidence of seizure activity.
A nurse is caring for a client who is 8 hr postoperative following a craniotomy. Which of the following actions should the nurse take? Suction the client every 2 hr. Report wound drainage greater than 50 mL/8 hr. Position the client flat in bed. Assess the client's neurologic status every 8 hr.
Report wound drainage greater than 50 mL/8 hr. Following a craniotomy, the client is at risk for hemorrhage and hypovolemic shock. The nurse should report wound drainage greater than 50 mL/8 hr.
A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect? Unilateral joint involvement Ulnar deviation Fractures of the spine Decreased sedimentation rate
Ulnar deviation The inflammation that occurs in the hand joints can make them susceptible to deformity from daily use. Ulnar deviation, or lateral deviation of the fingers, can occur from opening jars and other similar motions. Compression fractures of the spine are more common in clients who have osteoporosis. The client who has rheumatoid arthritis will have an increased sedimentation rate due to the body's response to the inflammatory connective tissue disorder.
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? -Hypoactive deep-tendon reflexes -Ascending paralysis -Intention tremors -Increased lacrimation
-Intention tremors. Clients who have multiple sclerosis are at risk for motor dysfunction, such as intention tremors, poor coordination, and loss of balance. Clients who have multiple sclerosis have HYPERactive deep-tendon reflexes. Clients who have Guillain-Barré syndrome are at risk for ascending paralysis. Increased lacrimation, or tearing of the eyes, is an expected finding of myasthenia gravis during a cholinergic crisis.
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? -Administer artificial tears. -Assist with Tensilon test. -Administer immunosuppressants. -Assist with plasmapheresis.
Assist with Tensilon test. The first action the nurse should take using the nursing process is to assess the client. The Tensilon test will determine whether the client is having a myasthenic crisis or a cholinergic crisis. The nurse should administer artificial tears because the client might have dry eyes due to an inability to close her eyes completely. The nurse should administer immunosuppressants, such as corticosteroids, methotrexate, or rituximab, to reduce the manifestations of myasthenia gravis. The nurse should assist with plasmapheresis, which removes antibodies from the plasma and reduces the manifestations of a myasthenic crisis. However, there is another action the nurse should take first.
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? Take this medication with 240 mL (8 oz) of milk. Remain upright for 30 min after taking this medication. Expect this medication to increase serum calcium levels. Increase vitamin D intake to promote medication absorption.
Remain UPright for 30 min after taking this medication. To prevent Esophagitis or Esophageal ulcers that can result from alendronate therapy, the client should sit up for 30 min after taking this medication and remain sitting until after eating the first meal of the day. instruct the client to take alendronate with 240 mL (8 oz) of WATER, not milk. Foods or beverages containing calcium can reduce medication absorption. Vitamin C intake does not increase alendronate absorption and some sources, such as orange juice, decrease absorption. However, the nurse should encourage the client to take Vitamin D, which promotes calcium absorption. Alendronate does not cause insomnia. Headache is a common adverse effect of alendronate.
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? Encourage the client to use the Valsalva maneuver. Administer a diuretic. Perform the Credé maneuver. Stroke the client's inner thigh.
Stroke the client's inner thigh. The nurse can stimulate micturition by stroking the client's inner thigh. Other techniques include pinching the skin above the groin and providing digital anal stimulation. Valsalva maneuver: hold his breath and bear down, to express urine from a Flaccid bladder. It is not effective with a Spastic bladder due to the spasticity of the external sphincter. the Credé maneuver: apply direct pressure over the client's bladder, to express urine from a flaccid bladder. It is not effective with a spastic bladder due to the spasticity of the External sphincter. Antispasmodics such as Oxybutynin, rather than diuretics, can be effective for treating mild spastic bladder problems.
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? -"There is a test for Alzheimer's disease that can establish a reliable diagnosis." -"The goal of medication therapy is to reverse the degenerative changes that can occur in brain tissue." -"Early manifestations of Alzheimer's disease include mild tremors and muscular rigidity." -"The drugs used to treat Alzheimer's disease can help delay cognitive changes."
"The drugs used to treat Alzheimer's disease can help delay cognitive changes." Medications used to treat Alzheimer's disease enhance the availability of acetylcholine allowing for greater response from cholinergic neurons in the brain, which can slow cognitive decline in some clients. There is no specific test for identifying Alzheimer's disease, except direct examination of the brain on autopsy. Providers diagnose Alzheimer's disease based on manifestations and by ruling out other diseases. None of the medications currently available reverse the course of Alzheimer's disease. Early manifestations include short-term memory loss, forgetfulness, and a shortened attention span. Mild tremors and muscular rigidity are manifestations of Parkinson's disease.
A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take? -Assess the client's neurologic status every 8 hr. -Initiate droplet precautions. -Check capillary refill at least every 4 hr. -Place the client in a well-lit environment.
-Monitor capillary refill at least every 4 hr. The nurse should perform a complete vascular assessment at least every 4 hr to monitor for Vascular Compromise. The nurse should assess the client's vital signs and neurologic status at LEAST every 2-4 hr. The nurse should implement Droplet precautions for clients who have Bacterial meningitis. Standard precautions are sufficient for clients who have viral meningitis. Place the client in a well-lit environment. Well-lit means artificial light. But for the viral meningitis pt, the nurse should minimize the client's exposure to light from windows and overhead lights because photophobia, or light sensitivity, is a manifestation of viral meningitis.
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. -Provide small doses of fentanyl via IV bolus for pain management. -Monitor body temperature every 1 to 2 hr. -Reposition the client every 2 hr.
Maintain a PaCO2 of approximately 35 mm Hg. The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at approximately 35 mm Hg to prevent hypercarbia and subsequent vasodilation effects that lead to increase in intracranial pressure. The nurse should administer opiate pain medications to reduce agitation and restlessness during mechanical ventilation and to manage pain. Fentanyl does not affect vital signs as much as morphine does, so it is a safer choice for this client. The nurse should monitor the client's body temperature because clients who have head injuries commonly develop a fever due to the body's response to the trauma or hypothalamic damage. The nurse should reposition the client at least every 2 hr to help prevent skin breakdown. However, this is not the nurse's priority.
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 Mydriatic ophthalmic drops Corticosteroid ophthalmic drops Epinephrine via IV bolus
Osmotic diuretics via IV bolus The nurse should administer osmotic diuretics to rapidly reduce intraocular pressure and prevent damage to the eye. Clients who have primary angle-closure glaucoma should not receive mydriatic ophthalmic drops because they cause pupillary dilation. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor. Corticosteroid ophthalmic drops are used for inflammatory conditions of the eye, such as conjunctivitis. There is no indication for clients who have primary angle-closure glaucoma to receive corticosteroid ophthalmic drops. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor. Clients who have primary angle-closure glaucoma should not receive epinephrine-containing medications because they cause vasoconstriction. Instead, the nurse should administer medications that decrease intraocular pressure by increasing the absorption or decreasing the production of aqueous humor.
A nurse is teaching an assistant personal about the care of total hip arthroplasty. Which is part should be including? -Avoid applying anti-embolism stockings to the affected leg. -Have the client lean forward when moving from a sitting to a standing position. -Discourage the client from sitting in a wheelchair with the back reclined. -Place an abductor pillow between the client's legs when turning the client.
Place an abductor pillow between the client's legs when turning the client. The nurse should inform the AP that a client who had a total hip arthroplasty should maintain the hip in abduction following surgery to reduce the risk of dislocating the surgical hip. The AP should place an abductor pillow between the client's legs when turning the client to keep her hips in abduction. a. The nurse should instruct the AP that a client who had a total hip arthroplasty should wear anti-embolism stockings on BOTH legs postoperatively to prevent the development of emboli in the lower extremities. b. should use the UNaffected leg and arms to push straight up to standing and not flex the affected hip more than 90°. c. can sit in either an upright wheelchair or one with a back that reclines to prevent hip flexion greater than 90°.
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? Check the client's cheek on his affected side after eating to be sure no food remains there. Encourage the client to sit upright with his head tilted slightly forward during meals. Provide the client with eating utensils that have large handles. Remind the client to look consciously at both sides of his meal tray.
Remind the client to look consciously at both sides of his meal tray. Clients who have right-sided homonymous hemianopsia have lost the right visual field of both eyes and might only eat the food he is able to see on the left half of the meal tray. Therefore, the nurse should remind the client to look at both sides of his meal tray to help him compensate for the visual loss. Homonymous hemianopsia does not cause the client to pocket food. However, food can accumulate on the affected side of the mouth, so the nurse should place food on the unaffected side of the client's mouth when feeding him. Homonymous hemianopsia does not cause dysphagia. However, as stroke can cause dysphagia, positioning the client upright and having him tilt his head forward to swallow can help prevent aspiration. Homonymous hemianopsia does not impair the client's fine motor skills. However, as stroke can impair fine motor skills, eating utensils that have a wide grip surface can help compensate for a weak hand grasp.
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? -Rinse with antiseptic mouthwash in place of using dental floss. -Use an over-the-counter antihistamine if a rash develops. -Slowly taper the medication after 6 consecutive months without seizure activity. -Take medications at a consistent time each day to maintain therapeutic blood levels.
Take medications at a consistent time each day to maintain therapeutic blood levels. The client should take antiepileptic medications on a regular schedule to maintain therapeutic blood levels and achieve maximum effect. Phenytoin can cause gingival hyperplasia, an overgrowth of gum tissue. To minimize gum injury and discomfort, the client should BRUSH and FLOSS after each meal, massage her gums, and schedule dental examinations regularly. The client should stop taking phenytoin and report the development of a rash to the provider immediately. An adverse effect of phenytoin therapy is the development of a measles-like rash. If left untreated, the rash could progress to Stevens-Johnson syndrome or toxic epidermal necrolysis.
