EAQ Neuromuscular

A nurse is counseling a client with amyotrophic lateral sclerosis (ALS) about management of this disorder. What important suggestion should the nurse make to the client?

"Activities should be spaced throughout the day."

The client is admitted to the emergency department after a fall from a roof. After determining that the client sustained a head injury, the nurse observes clear fluid coming from the client's left ear. What will the nurse do next?

Test the drainage from the client's ear with a glucose reagent strip

An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine is at the greatest risk for developing a pressure ulcer?

Sacrum

A nurse identifies that a client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, the nurse documents this gait as:

Shuffling

A client with a fractured head of the right femur and osteoporosis is placed in Buck's extension before surgical repair. What should the nurse do when caring for this client until surgery is performed?

Assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion

A client with myasthenia gravis experiences generalized weakness. What is most important when planning this client's nursing care?

Providing frequent rest periods

Immediately after cataract surgery a client complains of feeling nauseated. The nurse should:

Administer the prescribed antiemetic

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing?

Babinski

What is the primary responsibility of a nurse during a client's generalized motor seizure?

Clearing the immediate environment for client safety

A client is scheduled for arthroscopy of the knee in the morning and asks the nurse about the procedure. Which statement by the nurse best describes the procedure?

"It is a direct visualization of the joint to diagnose the extent of your knee injury."

The spouse of a client with an intracranial hemorrhage asks the nurse, "Why aren't they administering an anticoagulant?" How should the nurse respond?

"It is contraindicated because bleeding will increase."

A client who is scheduled for a muscle biopsy tells the nurse, "They better give me a general anesthetic. I don't want to feel anything." What is the most therapeutic response by the nurse?

"You seem to be worried about the test."

When entering a room on a medical unit, the nurse identifies that a client is having a seizure. What should the nurse do in addition to protecting the client from self-injury? Select all that apply.

-Monitor the seizure activity -Turn the client on the left side

A client with rheumatoid arthritis has been given a prescription for acetylsalicylic acid. The client asks the nurse, "What kind of drug is acetylsalicylic acid?" The nurse recalls that the classification to which this drug belongs is:

Analgesics

A nurse is caring for a client who sustained a transection of the spinal cord. The nurse continually monitors this client for what medical emergency?

Autonomic hyperreflexia

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, the nurse suspects the tumor is located in the:

Cerebellum

The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take?

Encourage the client to rest for short periods

After a painful exacerbation of rheumatoid arthritis, a client is scheduled to begin a walking and exercise program. What is an expected outcome for this client?

Exercise and be active unless the discomfort becomes too great.

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma?

Impairment of peripheral vision

When completing a neurological assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion?

Inability to stand with feet together when eyes are closed

A client with myasthenia gravis, who is living in a nursing home, experiences inadequate symptomatic control with pyridostigmine bromide (Mestinon), and long-term steroid therapy has been initiated. It is especially important for the nurse to ensure that the client:

Is monitored for an exacerbation of symptoms

After a client is treated for a spinal cord injury, the health care provider informs the family that the client is a paraplegic. The family asks the nurse what this means. What explanation should the nurse provide?

Lower extremities are paralyzed

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

Lowered level of consciousness

Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk?

Pain radiating to the hip and leg

After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." The nurse should:

Perform a complete pain assessment

A client's tibia is fractured in a motor vehicle accident, and a cast is applied. The nurse should assess for which manifestation indicating damage to major blood vessels caused by the fractured tibia?

Prolonged reperfusion of the toes after blanching

A client is admitted to the emergency department in the midst of persistent tonic-clonic seizures (status epilepticus). Diazepam (Valium) is to be administered immediately. The nurse anticipates that this drug will decrease central neuronal activity and:

Relax peripheral muscles

The health care provider prescribes one unit of packed red blood cells to be administered to the client who suffered a hip fracture. Several minutes after the start of the infusion, the client complains of itching. Upon further assessment, the nurse observes hives on the client's chest. Which action should the nurse take next?

Stop the transfusion immediately

A client is having a tonic-clonic seizure. Which of the following is a priority nursing action?

Take measurements to prevent injury

One week after an above-the-knee amputation, a client refuses to go to physical therapy and tells the nurse, "I'll never be a whole person again!" What is the nurse's best response?

"You've lost a part of yourself. That must be very difficult for you."

A nurse is caring for a client who just has had surgery on the ear. The nurse should assess for what early indicator of potential damage to the motor branch of the facial nerve?

Inability to wrinkle the forehead

A client has had a below-the-knee amputation of the leg. What is important for the nurse to consider when providing postoperative care for a client who had an amputation of a lower extremity?

The residual limb should be elevated the first 24 hours

Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a cerebrovascular accident (CVA, also known as "brain attack")?

Transient Ischemic Attacks (TIAs)

A young adult who is unconscious after an accident is brought to the emergency department. The client's pupils are equal and responsive to light. As part of the neurological assessment, the nurse applies a painful stimulus to the client's left lower leg. An expected response in a healthy adult is:

Withdrawing the leg

Bed rest is prescribed after a client's cerebrovascular accident (also known as "brain attack") results in hemiplegia. Which exercises should the nurse incorporate into the client's plan of care 24 hours after the brain attack?

Passive range-of-motion exercises