Exam 2 ATI questions

When a client asks what an EEG is for what is the nurses response?

" An EEG records the electrical activity of your brain cells"

Nursing is teaching a client with a new diagnosis of MS. The client asks about the usual causes of MS. What response should the nurse make?

"Acute episodes are usually followed by remissions, which can vary in duration"

Nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. Which statement by client indicates understanding?

"An aura is a sensory warning that a seizure is imminent"

Nurse is teaching a client about the adverse effects of baclofen to a client with MS. Which statement by the client indicates an understanding of the teaching?

"I should not stop taking this medication abruptly"

Nurse is teaching a client who has a cast on the left arm to treat a forearm fracture. Which statement indicates understanding by the client?

"I will call my doctors office if my fingers get colder on the arm with the cast"

Nurse is teaching a client who had an amputation of the left lower leg 3 days ago. Which statement indicates client understanding of how to care for the incision and left upper leg?

"I will lie on my stomach for 30 min a few times a day" -lying prone helps to prevent hip flexion contractures

Nurse is caring for a client with BKA and the client reports phantom pain. Which statement should the nurse make?

"This pain usually decreases over time as the limb becomes less sensitive" -heat compresses help this pain NOT cold

Nurse is teaching about levodopa w/ a family member of a client with PD. What info should the nurse provide?

"a full therapeutic response may take several months to happen"

Nurse caring for an MS patient who is on interferon beta-1a. What statement by the client indicates adverse effects of this med?

"my body aches all over" -causes flu-like symptoms

Nurse is providing teaching to client who has MS and a new prescription for baclofen PO. What info should the nurse provide the client?

"you should change positions slowly while taking this medication"

Nurse is caring for a client who is wearing a halo fixator. Which of the following interventions should the nurse implement? select all that apply.

-Monitor VS every 4 hr -Monitor pin sites for loosening -Check the client skin to ensure the jacket is not applying pressure *nurse should never hold or pull the halo device to turn client* *nurse should never adjust teh screws*

Nurse caring for a client with a hip fracture who has Buck's extension traction in place. what info should the nurse provide for this type of traction?

-you'll have considerably less pain with this in place -this traction will help decrease muscle spasms -the weights act as a pulling force to keep your leg and hip still

Nurse is caring for a client with a fractured hip. Which type of traction should the nurse expect the client to use?

Bucks traction

Nurse responds to a call for an assistive personal that a client had a seizure and is unconscious. Which of the following is the nurses priority?

Check airway patency - ABC

Nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?

Check cap refill before applying an ice pack to the affected area

Nurse assessing client who has a fractured left femur and is in a skeletal traction. Which finding should the nurse report to the provider?

Chest petechiae -indication of fat embolism

Which of the following fractures result when a clients bone breaks into multiple pieces?

Comminuted

Nurse is providing teaching about degenerative complications to a partner of a client with a new diagnosis of PD. Which manifestation is a priority?

Dysphagia -difficulty swallowing can lead to aspiration

Nurse in the ER is assessing a client who was in a MV crash 2 days ago and sustained fractures of his tibia, ulna, and several ribs. The client is now disoriented to time and place and has a SaO2 of 87%. The nurse notes generalized petechiae on the clients skin. Which of the following complications should the nurse suspect?

Fat embolism

Which type of fracture is especially common in children?

Greenstick

Nurse caring for a client who is in a skeletal traction following a femur fraction. The nurse finds that the client has slid toward the foot of the bed and the traction weight is resting on the floor. Which action should the nurse take?

Have the client use the trapeze to pull himself up while ensuring the weight hangs freely -weight always needs to hang freely to promote correct alignment of the extremity

which of the following comorbidities increases the clients risk of adverse effects of tizanidine?

Hepatitis -this drug is a muscle relaxant used for spacisity in MS

Nursing is preparing to administer dantrolene to a client with muscle spasticity. Which of the following findings in the clients medical history is a contraindication of this medication?

History of cirrhosis - this med can cause liver failure

Nurse is providing teaching to client with crutches. What instruction should the nurse include?

Keep the rubber crutch tips securely in place

Nurse is preparing to care for a client who is in a balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the plan of care?

Offer client a diet high in fluid and fiber -prevents constipation of an immobilized client

An ER nurse is assessing a client who has a new TBI. The nurse observe the extension of the clients arms & legs, pronation of the arms, and plantar flexion of the feet. What is the nurses priority?

Provide supplemental oxygen. ABC and then implement seizure precautions

Nurse is caring for a client who has a pelvic fracture. Client reports sudden SOB, stabbing chest pain, and feelings of doom. The client is experiencing what complication of a fracture?

Pulmonary embolism

Nurse is caring for a client who is 3 days post-op following a BKA. which action should the nurse take?

Rewrap the residual limb with an elastic bandage 3 x per day - helps to promote shrinkage

Nurse is assessing a client who is post op 48 hr after open reduction and internal fixation of a fractured tibia. What findings should the nurse report to the provider?

Toes that are cold to the touch

Nurse is caring for a client who is post op following a above the knee amputation. Which action should the nurse take?

assist the client into a prone position every 4 hr -nurse should avoid elevating the limb for the first 72 hr because this increases the risk of flexion contractures

Nurse is assessing a client who is 24 hr post op following an above the elbow amputation. Which of the following should the nurse identify as a priority?

client reports muscle spasms

what teaching should the nurse give for fiberglass cast care during the first 48 hours?

keep the cast above the level of your heart -to prevent edema, pain, and promote venous return

Nurse is caring for a school age client who has a skeletal traction to repair a pelvic fracture. Which of the following actions should the nurse take?

place the child on a pressure reduction mattress -prevents pressure on bony prominences

Nurse is providing discharge teaching to a family of a client who has a new diagnosis of seizure disorder. The nurse should instruct the clients family to take which of the following actions first in the event of a seizure?

protect the clients head - turning on the side and loosening clothing is done DURING a seizure not the first action

A nurse is providing teaching to a client who has history of tonic-clonic seizures and is scheduled for a standard EEG, which instruction should the nurse provide in the teaching?

thoroughly shampoo hair prior to the EEG

Nurse is caring for a client who begins to have a generalized tonic-clonic seizure while laying in bed. Which of the following actions should the nurse take?

turn the client onto their side