chapter 7 management

the rural emergency department nurse is triaging victims at the site of a disaster. the victims are tagged using a color code system. which client should be evacuated first? rank in order of priority.

-13245 -the client assigned a red tag who is alert and diagnosed with a sucking chest wound -the client assigned with a yellow tag whose abdomen is hard and tender to the touch -the client assigned a green tag who cannot stop crying and can't answer questions -the client assigned a black tag with full thickness burns on more than 60% of the body. -the client assigned a white tag who has no injuries adn is comforting the victims.

the 69 year old client post right cerebral vascular accident is on the rehab unit diagnosed with left sided weakness. where should the nurse place the quad can when assisting the client to ambulate?

-C

the RN rehabilitation unit nurse tels the UAP to assist the client recovering from guillain barre syndrome with a.m. care. which action by the UAP warrants immediate intervention?

-The UAP puts the side rails up when bathing the client.

the RN staff nurse, LPN, and UAP have been assigned to care for clients on a neurology unit. which nursing task is most appropriate to assign to the LPN?

-administer adrenocorticotropic hormone to the client diagnosed with multiple sclerosis.

The RN primary nurse and LPN are caring for a client diagnosed with a stroke. which intervention should the RN assign to the LPN?

-administer the client's anticoagulant subcutaneously

the nurse is on the day shift of a rehabilitation unit. given the following medication administration record, which medication should the nurse administer first?

-administer the morphine sulfate

the terminally ill client diagnosed with amyotrophic lateral sclerosis, also known as lou gehrig's disease has a DNR order in place and is currently reporting pain all over. the nurse notes the client has shallow breathing and a P 67, R 8, BP 104/62. which intervention should the nurse implement first?

-administer the narcotic pain medication IVP

the home health nurse is caring for a 22 year old female client who sustained an L-5 spinal cord injury 2 months ago. the client says, " i will never be happy again. I can't walk, i can't drive, and I had to quit college." which intervention should the nurse implement first?

-allow the client to express her feelings of powerlessness

the nurse is planning care for a client diagnosed with parkinson's disease. which client problem is priority?

-altered mobility

the nurse is administering medications for clients on a neurological unit. which medication should the nurse administer first?

-an anticholinesterase medication to a client diagnosed with myasthenia gravis

which task is most appropriate for the RN clinic nurse to delegate to the UAP?

-ask the UAP to escort the client in a wheelchair to the car.

the male client is in the emergency department after a fall, resulting in a closed head injury. the admitting nurse notes the client responds by opening his eyes and pushing the nurse's arm away when painful stimuli is applied but the client does not make any verbal response. which rating on the glasgow coma scale should be documented?

-client scored an 8 on the glasgow coma scale.

the nurse is teaching the client diagnosed with tension type headaches. which statement indicates the client needs more teaching?

-cold packs to the back of my neck will help with my headache.

the home health nruse is admitting a female client diagnosed with myasthenia gravis. the client tells the nurse, Even with my medication I get exhausted when i do anything. which intervention should the nurse implement?

-contact the HH occupational therapist to discuss the client's concerns

the home health aide tells the RN home health nurse the client diagnosed with multiple sclerosis is having problems getting out of the bed to the chair, and is now having problems getting into the shower. which intervention should the RN implement?

-contact the agency physical therapist about the situation.

the nurse is the first person on the scene of a motor vehicle accident. the driver is in the driver's seat unconscious. which intervention should the nurse implement first?

-ensure the driver has a patent airway

the RN primary nurse on the surgical unit is working with an UAP. which task is most appropriate for the RN to delegate to the UAP?

-escort a client who has been discharged to the client's vehicle.

the client in a multiple car crash dies in the emergency department. which priority intervention should the emergency department nurse implement when addressing the needs of the client's family?

-escort the family to a private room to grieve

the nurse caring for a client is accidentally stuck with the stylet used to start an IV infusion. which actions should the nurse implement next? rank in order of performance?

-flush the skin with water and attempt to get the area to bleed -notify the charge nurse and follow hospital protocol -have the laboratory draw the client's and the nurse's blood. -contact the infection control nurse to start post exposure prophylactic medication -follow up with the employee health nurse to have laboratory work drawn.

the client diagnosed with a CVA is confined to a wheelchair for most of the waking hours. which intervention is priority for the nurse to implement?

-get a pressure relieving cushion to place in the wheelchair

the clinic nurse is making assignments for the large family practice clinic. which task should be assigned to a staff nurse who is four months pregnant?

-have the staff nurse answer the telephone calls from clients.

the rehabilitation nurse is planning the discharge of a 68 year old client whose status post subarachnoid hemorrhage includes residual speech and balance deficits. which referral should the nurse initiate at this time?

-home health agency

the RN charge nurse observes the client's RN primary nurse telling the UAP to feed an elderly client diagnosed with CVA. which question should the charge nurse ask the client's nurse?

-how does the client swallow the medications

a client sustained a severe head injury, and his wife is concerned about what to do if he has a seizure when they go home. which statement indicates the wife understands the most important action to take if her husband has a seizure?

-i will move the furniture out of his way.

as the nurse enters the room of a newly admitted client, the client begins to have a tonic clonic seizure. which actions should the nurse implement? Select all that apply.

-identify the first area that began seizing -note the time the client's seizure began -provide the client with privacy during the seizure

the nurse in a long term care facility is developing the plan of care for a client diagnosed with end stage alzheimer's disease. which client problem is priority for this client?

-increased risk for injury

which priority client problem should be included in the care plan for the client diagnosed with guillain barre syndrome who is admitted to the critical care unit?

-ineffective breathing pattern

the client diagnosed with a CVA has residual right sided hemiparesis and difficulty swallowing, but is scheduled for discharge. which referral is most appropriate for the case manager to make at this time?

-inpatient rehabilitation unit

the client diagnosed with a c-6 SCI comes to the emergency department reporting a throbbing headache and has a BP of 200/120. which intervention should the nurse implement first?

-insert an indwelling urinary catheter.

the RN charge nurse is making rounds and notices that the sharps container in the client's room is above the fill line. which action should the charge nurse implement?

-instruct the UAP to change the sharps container

a client comes to the emergency department after having bleach splash in the eyes. which intervention should the nurse implement first?

-irrigate the eyes with sterile solution

the client is postoperative right eye enucleation. which statement indicates the client needs more discharge teaching?

-it will be approximately 2 weeks before I can get a prosthetic eye.

the 19 year old client is in the rehabilitation unit following a traumatic brain injury. which intervention should the RN staff nurse delegate to the UAP? select all that apply.

-make safety rounds hourly -assist the client with meals -clamp and unclamp the indwelling catheter every 2 hours.

the 24 year old diagnosed with a traumatic brain injury is being transferred to a rehabilitation unit. which health care provider order should the nurse question?

-methylprednisolone IVP q 6 h

the nurse in a long term care facility is administering medications to a group of clients. which medications should the nurse administer first?

-neostigmine to a client diagnosed with myasthenia gravis

the RN staff nurse and UAP are caring for a minimally responsive client diagnosed with multiple sclerosis who weighs more than 400 pounds. which action is priority when moving the client in the bed?

-obtain a lifting device made for lifting heavy clients.

the employee health nurse is caring for an employee who reports tripping and is describing right knee pain. there is no visible injury, and the client h as a normal neurovascular assessment. which intervention should the nurse implement?

-obtain a urine specimen for a drug screen.

the neurologist has explained to the family of a 22 year old client diagnosed with a traumatic brain injury placed on a ventilator after a motor vehicle accident that the client has no brain function. which referral is appropriate at this time?

-organ procurement organization

a wife tells the clinic nurse her husband had been fine and is now confused, doesn't know where he is, and is not acting the way he usually does. which intervention should the nurse implement first?

-perform a neurological assessment

the RN staff nurse is caring for a client diagnosed with Alzheimer's disease. which nursing tasks can the RN staff nurse delegate to the UAP? Select all that apply.

-perform the client's morning hygiene care -ambulate the client to the bathroom -obtain the client's routine vital signs.

the client diagnosed with a right sided CVA or stroke is admitted to the rehabilitation unit. which interventions should be included in the nursing care plan? select all that apply.

-position the client to prevent shoulder adduction -refer the client to occupational therapy daily -encourage the client to move the affected side -perform quadriceps exercises five times a day.

the nurse is caring for a client newly diagnosed with multiple sclerosis. which referral is appropriate at this time?

-psychological counselor for therapy

the multidisciplinary team is meeting to discuss a client diagnosed with right sided weakness who has developed a stage 2 pressure ulcer over the sacral area that is not healing. which priority intervention should the client's home health nurse recommend?

-recommend a referral to the home health care agency wound care nurse.

the employee health nurse is caring for an employee who fell off a ladder and is describing low back pain radiating down both legs. Which intervention should the nurse implement first?

-refer the client to an HCP for further evaluation.

the client being admitted with TIA is reporting a headache. the client is allergic to morphine, iodine, and codeine. which health care provider order should the nurse question?

-schedule for CT scan with contrast in am

to which collaborative health care team member should the RN critical care nurse refer the client in the late stages of MG?

-speech therapist

the nurse is at a park and observes a person fall and a stick become impaled into the right eye. which intervention should the nurse implement first?

-stabilize the stick in the accident victim's eye

the client nurse is providing discharge instructions to an elderly client diagnosed with cataracts. which interventions are important for the nurse to implement? select all that apply.

-teach the client to increase the light in the home -encourage the client to wear dark glasses outside -tell the family to avoid rearranging the furniture in the home -provide instructions with visual aids or large print.

a client is suspected of having bacterial meningitis and the nurse is assisting the health-care provider with a lumbar puncture. which intervention should the nurse implement first?

-tell the client to empty the bladder

the home health nurse enters the home of an 80 year old female client who had a CVA or stroke, 2 months ago. the client is reporting a severe headache. which intervention should the nurse implement first?

-tell the client to sit down, and take her blood pressure

the RN primary nurse and UAP are caring for a client diagnosed with right sided paralysis. which action by the UAP requires the RN to intervene?

-the UAP places her hand under the client's right axilla to help the client move up in bed.

the RN ICU nurse and UAP are caring for a client diagnosed with right-sided paralysis secondary to a cerebrovascular accident. which action by the UAP requires the RN to intervene?

-the UAP places the client on the abdomen with the head to the side.

the nurse in a rehabilitation facility is evaluating the progress of a female client who sustained a c-6, c-7 spinal cord injury. which outcome indicates the client is improving?

-the client can maneuver the automatic wheelchair into the hallway.

the home health nurse is scheduling visits for the day. which client should the nurse visit first?

-the client diagnosed with a C-5 SCI who reports redness and drainage at the halo vest sites

which client diagnosed with a SCI should the charge nurse assess first after receiving the change of shift report?

-the client diagnosed with a C-6 SCI who is describing dyspnea symptoms and has a respiratory rate of 12 breaths per minute

the nurse has just received the shift report. which client should the nurse assess first?

-the client diagnosed with a C-6 spinal cord injury who has autonomic dysreflexia

the nurse in the neurological clinic is triaging phone calls. which client should the nurse contact first?

-the client diagnosed with a tension headache wh ois reporting nausea and vomitting

the critical care RN charge nurse is making client assignments for the shift. which client should the charge nurse assign to the graduate nurse who just completed orientation?

-the client diagnosed with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at the bedside.

the nurse is caring for clients in the emergency department. which client should the nurse assess first?

-the client diagnosed with an epidural hematoma

the nurse is triaging phone calls in a neurosensory clinic. which client should the nurse contact first?

-the client diagnosed with external otitis who has serosanguineous drainage and otalgia

the nurse is caring for clients in a long term care facility. which client should the nurse assess first after receiving the morning report?

-the client diagnosed with parkinson's disease who began to hallucinate during the night.

the nurse is caring for clients in an ophthalmology clinic. which client warrants intervention by the nurse?

-the client diagnosed with primary open angle glaucoma who reports excruciating eye pain.

the critical care nurse is caring for a client diagnosed with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later which data would warrant immediate intervention?

-the client extends the upper and lower extremities in response to painful stimuli.

the charge nurse has recieved laboratory data for clients in the medical department. which client would require intervention by the charge nurse?

-the client receiving phenytoin who has serum levels of 24 mcg/dL

the clinic nurse is triaging client telephone calls. which client should the nurse call first?

-the client who has vomiting and abdominal cramping pain and a friend with botulism.

the charge nurse is making client assignments for a neurological medical floor. which client should be assigned to the most experienced nurse?

-the elderly client who is experiencing a stroke in evolution

the nurse is administering medications on a neurological unit. which medication should the nurse administer first?

-the osmotic diuretic to the client diagnosed with a closed head injury

the client on the rehab unit post motor vehicle accident has been prescribed 50 mg of baclofen per dose orally for muscle spasms. Baclofen comes in 10 mg, 20 mg, and 75 mg tablets. how. many tablets should the nurse administer and in which quantity?

-two 20 and one 10 tablet

the RN charge nurse observes the new graduate nurse delegating tasks to the UAP and the UAP appears to be ignoring the graduate nurse. which action should the charge nurse implement first?

-wait and observe how the graduate nurse handles the situation.

the wife of a client diagnosed with a brain tumor tells the nurse, "i don't know how I will make it if something happens to my husband. I love him so much" which statement is most appropriate for the nurse?

-you don't know how you will make it if something happens