exam 5 black and hawk nursing book

Important discharge instructions for the client with a cervical disk problem being discharged with a cervical collar include a.)ambulate carefully to avoid falls. b.)perform active range-of-motion exercises four times daily. c.)release the Velcro strap every 2 hours while awake. d.)wash the collar with mild soap and water daily.

a.)ambulate carefully to avoid falls.

The nurse outlines that the usual remedy to achieve wrist rest for a client with carpal tunnel syndrome is a.)applying a wrist splint. b.)encouraging use of analgesics. c.)supporting the hand on a pillow. d.)using a special adaptor on a keyboard.

a.)applying a wrist splint

On the first postoperative day, a client who had a cervical surgery requests the bedpan often, but cannot void. Based on these observations, the nurse should a.)assess for bladder distention. b.)assess for manifestations of urinary tract infection. c.)document this outcome as normal. d.)increase fluid intake.

a.)assess for bladder distention.

The nurse would assess the client with a history of TIAs for a.)ataxia and dysarthria. b.)bouts of hypertension. c.)nausea and vomiting. d._tingling in the extremities.

a.)ataxia and dysarthria.

he nurse would question a client with suspected trigeminal neuralgia about facial pain that is a.)characterized by intermittent episodes of severe pain with gradual onset. b.)characterized by intermittent episodes of severe pain with sudden onset. c.)constant and aching or burning in nature. d.)constant, severe, and sharp in nature.

b.)characterized by intermittent episodes of severe pain with sudden onset.

The nurse would suggest to the family of a client who is in the moderate stages of AD and is being cared for in the home to (Select all that apply) a.)assess orientation hourly by hiring a sitter if necessary. b.)disable the stove but find ways for the client to participate in meal preparation. c.)have the client wear an identification badge. d.)move knickknacks to the middle of tables. e.)secure the environment with a fence so the client cannot leave the home.

b.)disable the stove but find ways for the client to participate in meal preparation. c.)have the client wear an identification badge. d.)move knickknacks to the middle of tables. e.)secure the environment with a fence so the client cannot leave the home.

An elderly client who was found unresponsive at home now opens his eyes when spoken to and answers simple questions when asked; and left alone usually sleeps. The nurse would document this information in the Glasgow Coma Scale using the categories of a.)best verbal response and best motor response. b.)eye opening and best verbal response. c.)eye opening and motor activity. d.)motor activity and motor response.

b.)eye opening and best verbal response.

A client had a stroke. A nurse has arranged a consultation with an occupational therapist in order to enhance the client's ability to a.)acquire job skills. b.)feed himself. c.)swallow. d.)use a walker.

b.)feed himself.

Health promotion activities the nurse could suggest to a community group for Huntington's disease include a.)Eating foods high in omega-3 fatty acids. b.)genetic screening for high-risk individuals. c.)limiting exposure to heavy metals. d.)taking 400 International Units of vitamin E daily.

b.)genetic screening for high-risk individuals.

Before the administration of the first dose of carbamazepine (Tegretol) to a client with trigeminal neuralgia, the nurse should a.)assess the client's deep tendon reflexes. b.)check the client's blood pressure. c.)determine if the client abuses alcohol. d.)remind the client to remain in bed for 20 minutes after receiving the drug.

c.)determine if the client abuses alcohol.

While caring for a spinal cord-injured client, the nurse notes that he is flushed and sweating profusely, complaining of headache and nausea, and that his blood pressure is elevated with a slow pulse rate. The priority intervention should be to a.)administer antihypertensive medication. b.)check for a distended bladder. c.)elevate the head of the bed to a sitting position. d.)notify the physician immediately.

c.)elevate the head of the bed to a sitting position.

The nurse formulates the following nursing diagnosis for a client with MS: Impaired Physical Mobility related to muscle weakness. Useful interventions the nurse could plan include a.)encouraging long naps or rest periods. b.)encouraging strengthening exercises for affected muscles every 4 hours. c.)having the client perform ROM exercises at least two times daily. d.)performing all the activities of daily living (ADLs) for the client.

c.)having the client perform ROM exercises at least two times daily.

A client with MS is being taught self-care measures to prevent constipation. The nurse would realize goals for teaching had been met when the client states he/she will avoid a.)a high-fiber diet. b.)citrus fruits. c.)laxatives. d._stool softeners.

c.)laxatives.

The nurse encourages the client who has sustained a C5 complete spinal cord injury that he should anticipate that he will be able to a.)dress totally independently. b.)feed himself. c.)learn to type or use a computer. d.)self-catheterize.

c.)learn to type or use a computer.

A priority nursing intervention for a client in the emergency department with a suspected spinal cord injury is to a.)administer mannitol. b.)give a tetanus booster shot. c.)logroll the client. d.)obtain a thorough history.

c.)logroll the client.

When a client has undergone a carotid endarterectomy and has been returned to the nursing unit with stable vital signs, the nurse should a.)assess neurologic status every 4 hours. b.)keep the client in a flat, supine position with the head flexed. c.)maintain blood pressure within 20 mm Hg of the preoperative values. d.)provide neck range-of-motion exercises every 8 hours.

c.)maintain blood pressure within 20 mm Hg of the preoperative values

A nurse teaches a community class about primary prevention for stroke, which includes (Select all that apply) a.)adequate control of hypertension. b.)keeping tight glycemic control in diabetes. c.)maintaining safe cholesterol levels. d.)not smoking or smoking cessation. e.)reducing heavy alcohol consumption.

c.)maintaining safe cholesterol levels. d.)not smoking or smoking cessation. e.)reducing heavy alcohol consumption.

A male client with a spinal cord injury at the level of C5 is despondent relative to the termination of sexual relations because of his injury. The nurse counsels that erections are possible with a.)heat pack to the scrotum. b.)manual stimulation. c.)penile implant. d.)visual imagery.

c.)penile implant.

he most helpful intervention by the nurse for a client experiencing a parkinsonian crisis would be to a.)administer oxygen by nasal catheter. b.)give the client IV fluids that contain potassium. c.)place the client in a nonstimulating environment. d.)provide the client with foods high in calcium.

c.)place the client in a nonstimulating environment.

The nurse reminds a group of students about the major component of pathophysiology in multiple sclerosis (MS), which is a.)damage occurs primarily to the dendrites and oligodendrites. b.)once damaged, myelin cannot regenerate at all. c.)plaques occur anywhere in the white matter of the central nervous system (CNS). d.)Schwann cells are destroyed slowly but relentlessly.

c.)plaques occur anywhere in the white matter of the central nervous system (CNS

When the spouse of a client who has had a CVA as a result of a cerebral hemorrhage asks the nurse about the client's chances for recovery, the nurse should base a reply on knowledge that with this type of CVA a.)improvement generally occurs over several days. b.)rapid improvement often occurs. c.)recovery is slow and less complete. d.)there is no way to know for sure.

c.)recovery is slow and less complete.

The nurse would assist the client with low back pain resulting from herniated lumbar disk into the position of a.)either to the right or left side with knees straight. b.)prone with a very small pillow under the head. c.)side-lying with knees flexed. d.)supine with head elevated 90 degrees.

c.)side-lying with knees flexed.

The nurse would recommend that the habit that should be modified to reduce the incidence of back pain is a.)eating a high-fiber diet. b.)mild exercise three times a week. c.)sitting for long periods, rather than standing. d.)using leg muscles when lifting.

c.)sitting for long periods, rather than standing.

The nurse explains to a family that immediate medical-surgical stabilization after a severe cervical injury would include a.)cervical brace. b.)halo jacket. c.)skeletal traction. d.)spinal fusion.

c.)skeletal traction.

The emergency department nurse should position the client with cranial injuries a.)in high-Fowler position and knees elevated. b.)side-lying with head of bed elevated 20 degrees. c.)supine with head of bed elevated 30 degrees. d.)supine with the bed completely flat.

c.)supine with head of bed elevated 30 degrees.

To assist the client with Parkinson's disease to reduce tremor, the nurse suggests that the client a.)clasp arms about self and squeeze. b.)sleep on the non-tremorous side. c.)tightly hold change in the pocket. d.)visualize stilling the tremor.

c.)tightly hold change in the pocket.

he nurse teaches a group of high school students that the best way to avoid a spinal cord injury is to avoid a.)cervical spondylosis. b.)myelitis. c.)trauma. d.)vascular disease.

c.)trauma.

The nursing action that would be appropriate in caring for a client who has experienced stroke because of hemorrhage is to a.)maintain the head of the bed in a flat position. b.)monitor rectal temperature every 4 hours. c.)teach isometric exercises. d.)teach the client to avoid the Valsalva maneuver.

d.)teach the client to avoid the Valsalva maneuver.

A client has a history of experiencing focal neurologic deficits, such as slurred speech and facial weakness, that last for a few hours at a time. The nurse then assesses this client for other possible manifestations of a.)embolic stroke. b.)encephalopathy. c.)intracranial hemorrhage. d.)transient ischemic attacks (TIAs).

d.)transient ischemic attacks (TIAs).

The nurse would instruct a client who has undergone microvascular decompression surgery of the trigeminal nerve to a.)chew on the affected side of the mouth. b.)eat foods that are very warm or very cold for better taste. c.)resume a full diet immediately. d.)use a water jet device instead of a toothbrush.

d.)use a water jet device instead of a toothbrush.

A nurse is caring for a client diagnosed with Creutzfeldt-Jakob Disease (CJD). Appropriate nursing care includes a.)administering broad-spectrum antibiotics until culture results are known. b.)giving the client anti-viral medications as ordered. c.)placing the client in contact and airborne isolation. d.)using standard precautions when handling body fluids.

d.)using standard precautions when handling body fluids.

The critical care nurse explains to the family of a client who is to receive nimodipine following hemorrhagic stroke that the purpose of this drug is to treat a.)dizziness. b.)hypertension. c.)spasticity. d.)vasospasm.

d.)vasospasm.

To assess motor response, the nurse performing a neurologic assessment on a client in a coma would ask the client to a.)cough and deep breathe. b.)grasp the nurse's fingers. c.)repeat a phrase. d.)wiggle the toes.

d.)wiggle the toes.

The nurse has consulted with the interdisciplinary stroke team to facilitate a client's discharge to home from the rehabilitation facility. The occupational therapist recommends a therapeutic day pass. The nurse explains to the family that the purpose of the pass is to (Select all that apply) a.)allow the client to practice self-care skills. b.)evaluate the accessibility and safety of the home. c.)help the family adjust to the client's presence. d.)improve transition back into the community. e.)reduce the cost of the rehabilitation stay.

a.)allow the client to practice self-care skills. c.)help the family adjust to the client's presence. d.)improve transition back into the community.

On the second postoperative day following herniated disk surgery, the client says, "My legs are numb. I thought surgery was going to fix my problems." The nurse's best response to explain the continued pain is a.)"Because of the surgery, there is some swelling, which should subside." b.)"This pain is from the anesthesia and will subside by this afternoon." c.)"This pain is positional and will subside if you roll over on your side." d.)"You are probably moving around too much. I will raise the knee gatch."

a.)"Because of the surgery, there is some swelling, which should subside."

A nurse is performing an assessment on a client who is suspected of having MG. The complaint made by the client that reflects a manifestation commonly seen in clients with this disease is a.)"By the end of the day, my eyelids usually are drooping." b.)"I have a great deal of difficulty getting up after I rest for a while." c.)"I perspire more then I ever have in the past." d.)"When I have a cold, I usually have a strong cough with it."

a.)"By the end of the day, my eyelids usually are drooping."

Which interventions should the nurse plan to encourage the client to become proficient in self-administering his/her own medications? (Select all that apply.) a.)Allow the client to assume greater responsibility for taking medications. b.)Create a clear, concise drug chart including all the client's medications. c.)Encourage the client to take medications under supervision of a family member. d.)Provide a supervised trial of self-administration of medications. e.)Teach the client pertinent information about each medication.

a.)Allow the client to assume greater responsibility for taking medications. b.)Create a clear, concise drug chart including all the client's medications. d.)Provide a supervised trial of self-administration of medications. e.)Teach the client pertinent information about each medication.

Important self-care measures a nurse can teach a client with Parkinson's disease in order to prevent contractures and improve mobility include which of the following? (Select all that apply.) a.)Bend over with your head over your toes to get out of chairs. b.)Exercise first thing in the morning. c.)Keep a narrow-based gait. d.)Look up when you walk, not down at the floor. e.)Use a firm surface, like the floor, for exercising.

a.)Bend over with your head over your toes to get out of chairs. b.)Exercise first thing in the morning. d.)Look up when you walk, not down at the floor.

A client who has had a stroke appears to understand words that are spoken but cannot verbally respond. The nurse clarifies that this type of aphasia is a.)Broca's. b.)global. c.)receptive. d.)Wernicke's.

a.)Broca's.

The nurse instructs a group of nursing students that the pathologic changes that occur in the brain of a person with dementia of Alzheimer's disease include a.)abnormal accumulation of proteins. b.)damage to the myelin sheath of neurons. c.)destruction of neurons. d.)increase in production of cerebrospinal fluid (CSF).

a.)abnormal accumulation of proteins.

The nurse cautions clients with ALS and their families to be aware that (Select all that apply) a.)activities should be spaced throughout the day. b.)clients experience incontinence, an early cause of falling. c.)cognition will usually decline late in the disease. d.)muscle weakness may cause a risk for injury.

a.)activities should be spaced throughout the day. d.)muscle weakness may cause a risk for injury.

When the client who had a cervical spinal fusion this morning complains of a sudden radicular pain, the nurse is a.)alerted because this indicates possible infection. b.)concerned because this indicates possible meningitis. c.)distressed because of the possible need to repeat the surgery. d.)relieved because this indicates a reduction in edema.

a.)alerted because this indicates possible infection.

To promote back health, nursing personnel are instructed in good body mechanics, which include (Select all that apply) a.)avoid twisting the body when lifting. b.)hold objects away from the body when lifting in case they are dropped. c.)keep heavy objects close to the body when lifting. d.)participate in exercises to strengthen abdominal and back muscles.

a.)avoid twisting the body when lifting. c.)keep heavy objects close to the body when lifting. d.)participate in exercises to strengthen abdominal and back muscles.

A client arrives in the emergency department after being involved in a motor vehicle accident; the client exhibits a complete loss of motor, sensory, autonomic, and reflex activity below the injury level. The nurse can determine if he is experiencing spinal shock by assessing a.)blood pressure and pulse rate. b.)for muscle spasm. c.)the presence of bowel sounds. d.)the pupillary response.

a.)blood pressure and pulse rate.

To best help the client who has the nursing diagnosis Ineffective Coping after a stroke, the nurse would a.)break a long-term goal into smaller pieces. b.)listen to the client carefully and try to understand. c.)place familiar items, such as photos, near the bed. d.)redirect the client when inappropriate behavior occurs.

a.)break a long-term goal into smaller pieces.

A client who had a thrombotic stroke finished receiving intravenous rt-PA therapy at 10:00 AM on Sunday. Sunday afternoon the physician writes an order to start Coumadin and Plavix that evening. The most appropriate action by the nurse would be to a.)call the physician and clarify when the medications should be given. b.)consult with the pharmacist about giving both medications together. c.)give the Coumadin at 5:00 PM because that is the standard administration time. d.)provide appropriate education and administer the medications as ordered.

a.)call the physician and clarify when the medications should be given.

Urinary complications can be prevented if the nurse adjusts the care plan to include a.)checking for post void residuals. b.)encouraging voiding every 2 hours. c.)monitoring the client's urinalysis. d.)placing an indwelling Foley catheter.

a.)checking for post void residuals.

Self-care measures the nurse or speech therapist should teach the client who has residual dysphagia after a stroke include (Select all that apply) a.)chewing each bite thoroughly. b.)placing foods in the unaffected side of the mouth. c.)sticking to only semi-liquids and very soft foods. d.)turning the head to the unaffected side and checking for retained food.

a.)chewing each bite thoroughly. b.)placing foods in the unaffected side of the mouth. d.)turning the head to the unaffected side and checking for retained food.

The spouse of a client who suffers from chronic back pain is exasperated by the client's crankiness and sarcastic way of talking. The nurse should base a response to the spouse based on the knowledge that a.)chronic pain can lead to depression and personality changes. b.)clients with back pain often become addicted to narcotics. c.)often spouses are not supportive and this frustrates the clients. d.)when clients are non-compliant with treatment plans, they often act out.

a.)chronic pain can lead to depression and personality changes.

The nurse points out the physical therapy modality that would be avoided in the treatment for a client with Bell's palsy is a.)cold packs. b.)facial nerve stimulation with faradic current. c.)gentle massage. d.)moist heat.

a.)cold packs.

Nursing activities for a client with ALS and family include helping them a.)decide on an acceptable level of care early in the course of the disease. b.)determine if they want to share the diagnosis to allow genetic testing. c.)incorporate nonpharmacologic pain control techniques in the plan of care. d.)plan for extensive rehabilitation after exacerbations.

a.)decide on an acceptable level of care early in the course of the disease.

The nurse encourages a stroke victim by telling them that following a cerebrovascular accident (CVA) caused by thrombosis, the client's condition may improve after several days as a result of a.)decrease of edema in the area. b.)formation of collateral blood circulation. c.)formation of new nervous pathways. d.)reabsorption of the thrombus.

a.)decrease of edema in the area.

The assessment the nurse documents that supports the finding of apraxia would be the client's inability to a.)get dressed independently. b.)recognize a pencil. c.)see far objects. d.)understand the spoken word.

a.)get dressed independently.

A client with stroke has a nursing diagnosis of Impaired Verbal Communication and has specific difficulty in verbal expression. The most helpful strategy by the nurse would be to a.)give the client practice in repeating words after the nurse. b.)point to objects and state their names. c.)repeat directions until they are understood. d.)try to do all the speaking for the client.

a.)give the client practice in repeating words after the nurse.

When a client with upper motor neuron damage following a spinal cord injury is experiencing a neurogenic bowel, the nurse would alter the plan of care to include a.)giving a suppository daily. b.)having the client take a daily laxative. c.)instilling daily soapsuds enemas. d.)manually disimpacting the stool.

a.)giving a suppository daily.

A client has had two TIAs. Priority nursing actions focus on a.)helping the client reduce risk factors for stroke. b.)providing emotional support during this stressful time. c.)teaching the client's family about rehabilitation. d.)working with a speech therapist on speech problems.

a.)helping the client reduce risk factors for stroke.

An emergency department nurse is admitting a client with ischemic stroke who is eligible for thrombolytic therapy. The nurse works quickly to provide care, knowing that for this therapy to be effective, it must be administered in a post-stroke time window of a.)30 minutes. b.)3 hours. c.)6 hours. d.)12 hours.

b.)3 hours.

A client with acute disk herniation began using ice for analgesia along with medication therapy. The nurse explains that the client will be switched to heat therapy after a.)24 hours. b.)48 hours. c.)72 hours. d.)96 hours.

b.)48 hours.

Following a spinal cord injury, assessment revealed left-side motor paralysis with loss of vibratory and position sense, and right-side loss of pain and temperature sensation. The nurse recognizes the spinal cord syndrome of a.)anterior cord syndrome. b.)Brown-Séquard syndrome. c.)central cord syndrome. d.)spinal shock syndrome.

b.)Brown-Séquard syndrome.

The nurse is caring for a client who had a stroke several years ago. The client has indicators of being malnourished. The nurse would assess the client for which of the following? a.)Ability to throw the head back to propel the food b.)Embarrassment and frustration over trouble eating c.)Inability of the bowel to absorb nutrients d.)Positioning the head with a sideways' tilt

b.)Embarrassment and frustration over trouble eating

A client has returned to the nursing unit after having a cervical fusion from the anterior approach. What piece of equipment does the nurse ensure is at the bedside? a.)A patient-controlled analgesia (PCA) pump b.)Emergency tracheostomy set c.)Humidified oxygen d.)Suction setup and rigid suction catheter

b.)Emergency tracheostomy set

The nurse is assessing a client for manifestations of recovery from spinal shock. Which of the following assessment findings would indicate that spinal shock is resolving? a.)Flaccid paralysis b.)Hyperreflexia c.)Loss of Babinski's response d.)Urinary retention

b.)Hyperreflexia

A client is admitted to the hospital with right-sided hemiplegia as a result of a stroke. To help prevent contractures, the nurse should employ which of the following interventions? (Select all that apply.) a.)Give the client a ball to hold to keep fingers in the flexed position. b.)Perform passive ROM to affected limbs at least twice a day after the first 24 hours. c.)Support a completely flaccid arm with pillows when in bed or in a chair. d.)Try placing the client in the prone position for 15-30 minutes at a time. e.)Use high-top tennis shoes or orthotics while in bed to prevent footdrop.

b.)Perform passive ROM to affected limbs at least twice a day after the first 24 hours. c.)Support a completely flaccid arm with pillows when in bed or in a chair. d.)Try placing the client in the prone position for 15-30 minutes at a time. e.)Use high-top tennis shoes or orthotics while in bed to prevent footdrop.

The nurse explains that the pathology of Huntington's disease involves a.)a decrease in the neurotransmitter norepinephrine. b.)an excess of the neurotransmitter dopamine. c.)destruction of white matter in the brain. d.)formation of neurofibrillary tangles and plaques.

b.)an excess of the neurotransmitter dopamine

A client with MG began to experience a sudden worsening of her condition with difficulty in breathing. The nurse explains that this complication of MG is usually initially treated with a.)admission and administration of IV corticosteroids. b.)an increased dose of anticholinesterase drugs. c.)bolus doses of atropine titrated to effect. d.)rest and increased sleep.

b.)an increased dose of anticholinesterase drugs.

A client with a spinal cord lesion experiences a sudden, painful spasm of his lower limbs. The priority action by the nurse is to a.)administer pain medication. b.)assess for bladder distention. c.)massage the client's legs. d.)position the client upright.

b.)assess for bladder distention.

A client who has left hemiparesis as a result of stroke is getting out of bed to the chair for the first time. The nurse should position the chair a.)at a right angle to the client's left side. b.)at a right angle to the client's right side. c.)facing away from the side of the bed. d.)facing the side of the bed but within 1 foot.

b.)at a right angle to the client's right side.

Nursing interventions to support the family caring for a client with Alzheimer's disease include (Select all that apply) a.)encouraging emotion-focused coping mechanisms. b.)helping the family identify safety concerns and modifying the home. c.)showing the family how to deal with behavioral problems. d.)teaching the family alternative communication techniques.

b.)helping the family identify safety concerns and modifying the home. c.)showing the family how to deal with behavioral problems. d.)teaching the family alternative communication techniques.

When the nurse caring for a client using an ICP monitor reads ICP as 20 mm Hg, the nurse would interpret this as a.)an incorrect reading. b.)higher than normal. c.)lower than normal. d.)normal.

b.)higher than normal.

A client is being treated in the clinic for an exacerbation of multiple sclerosis. The nurse would anticipate administering which drug? a.)Diazepam (Valium) b.)interferon b1b (Betaseron) c.)Lioresal (Baclofen) d.)Methylprednisolone (Solu-Cortef)

b.)interferon b1b (Betaseron)

In performing a neurologic evaluation of a client who had lumbar surgery 36 hours ago, it is important that the nurse assess a.)ability to move shoulders. b.)leg movement. c.)level of consciousness. d.)reflex response.

b.)leg movement.

The nurse explains that the assessment of the salivary nicotine levels before a spinal fusion surgery is done to reduce the risk of a.)cardiac dysrhythmias. b.)nonunion. c.)sudden hypertension. d.)vasospasm.

b.)nonunion.

The point the nurse should stress in giving home instructions to the client regarding home care following carpal tunnel release surgery is a.)flex and extend the fingers every 4 hours while awake. b.)notify the physician if part of the hand becomes cold or tingly. c.)restrict lifting for 2 weeks. d.)wear a splint for 24 to 48 hours.

b.)notify the physician if part of the hand becomes cold or tingly.

The client who is unconscious following a fall has a blood pressure of mm Hg. The most appropriate action by the nurse is to a.)increase the patient's intravenous (IV) fluids. b.)notify the physician immediately. c.)provide hyperventilation by adjusting ventilator settings. d.)retake the blood pressure in 15 minutes.

b.)notify the physician immediately.

To prevent complications caused by a common problem of Huntington's disease, the nurse should a.)institute seizure precautions. b.)pad wheelchairs and beds. c.)start an exercise regimen. d.)teach different communication signals.

b.)pad wheelchairs and beds.

To promote safety, when a client complains of the effects of diplopia after a stroke, the nurse would a.)approach the client on the unaffected side. b.)place a patch over one eye. c.)reassure the client that the problem is temporary. d.)teach eye muscle exercises.

b.)place a patch over one eye.

A client with advanced ALS is admitted to the hospital. Because of manifestations that are common in clients with ALS, the nurse should a.)attempt to institute bowel-training activities. b.)provide the client with small, frequent feedings. c.)obtain an order for intermittent catheterization. d.)orient the client to his or her surroundings frequently.

b.)provide the client with small, frequent feedings.

The nurse assesses agnosia in a client who had a CVA. An example of this disturbance would be an inability to a.)read and comprehend writing. b.)recognize eating utensils. c.)see past the midline. d.)use the limbs purposefully.

b.)recognize eating utensils.

When a client is admitted to the hospital with Guillain-Barré syndrome (GBS), the most important assessment the nurse should make is for a.)decreasing alertness. b.)respiratory difficulty. c.)seizure activity. d.)urinary retention.

b.)respiratory difficulty.

The nurse should assess a client who has had unrelieved trigeminal neuralgia for the past 6 months for a.)alcohol consumption. b.)suicidal ideation. c.)vocational rehabilitation. d.)weight gain.

b.)suicidal ideation.

Safety precautions the nurse instructs the client with homonymous hemianopsia to use include a.)getting evaluated for prescription lenses. b.)turning the head to scan the visual field. c.)using artificial tears to keep the eyes moist. d.)wearing an eye patch on alternating eyes.

b.)turning the head to scan the visual field.

A client is receiving donepezil (Aricept) for moderate Alzheimer's disease. The nurse would assess that teaching goals for this medication have been met when the client's spouse says a.)"Aricept works by blocking oxygen free radicals in the brain." b.)" Depression has been the worst part so I'm glad this pill will control it." c.)"I'm anxious to see how much improvement the medications allows." d.)"This medicine will prevent further deterioration in condition."

c.)"I'm anxious to see how much improvement the medications allows."

A client is assessed as being in the mild stage of Alzheimer's disease (AD). The nurse recognizes the complaint made by the client's family that is most closely related to the diagnosis is that the client a.)"has difficulty using simple things, such as her toothbrush or comb." b.)"seems to have lost control over her bowels." c.)"seems indifferent about things she used to care about." d.)"uses words in the wrong context."

c.)"seems indifferent about things she used to care about."

When the client who has an incomplete lesion of the spinal cord complains of more weakness in his upper extremities than in his lower extremities, the nurse recognizes these manifestations to be consistent with a.)anterior cord syndrome. b.)Brown-Séquard syndrome. c.)central cord syndrome. d.)cervical cord syndrome.

c.)central cord syndrome.

A client with Bell's palsy tells the nurse that s/he is very depressed about having the disease. The most informative response from the nurse would be a.)"Bell's palsy can be treated successfully with medication." b.)"I understand how you feel; it is difficult to live with a chronic disease." c.)"Surgery has been very successful in improving the problem." d.)"The symptoms are likely to disappear or get better within a few weeks."

d.)"The symptoms are likely to disappear or get better within a few weeks

The nurse explains that irreversible brain tissue damage is probable when the blood flow to the brain is reduced by a.)10%. b.)30%. c.)40%. d.)60%.

d.)60%.

A client tells the nurse that he is experiencing some leg stiffness when walking and slowness when performing ADLs. Occasionally he has noted slight tremors in his hands at rest. This information leads the nurse to suspect a.)amyotrophic lateral sclerosis (ALS). b.)Huntington's disease. c.)myasthenia gravis (MG). d.)Parkinson's disease (PD).

d.)Parkinson's disease (PD).

A client has received thrombolytic therapy for treatment of an ischemic stroke. Which intervention takes priority? a.)Assessing nutritional status and planning feeding b.)Consulting with the interdisciplinary stroke team c.)Providing client and family education d.)Stringent blood pressure control

d.)Stringent blood pressure control

When the nurse assesses brain tissue extruding through an unstable skull fracture, it is documented as which type of herniation syndrome? a.)Central transtentorial b.)Cingulate c.)Tonsillar d.)Transcalvarial

d.)Transcalvarial

A client who experienced a stroke that left residual left hemiplegia will not wash the left side or use her good limbs on the right to move or adjust the limbs on the left. The most appropriate diagnosis for this client is a.)Altered Physical Mobility. b.)Ineffective Coping. c.)Self-Care Deficit. d.)Unilateral Neglect.

d.)Unilateral Neglect.

The nurse instructs a group of secretaries that which activities could prevent carpal tunnel syndrome? a.)Getting up and walking every hour b.)Routine use of nonsteroidal anti-inflammatory medication c.)Splinting and elevation of the hand d.)Worksite evaluation and modifications

d.)Worksite evaluation and modifications

The client hospitalized for severe lumbar disk pain asks the nurse to equip his bed with a trapeze. In response to this request, the nurse should a.)apply the trapeze mount to the bed. b.)call the physician for an order for the trapeze. c.)delay applying the trapeze mount until the client is more comfortable. d.)explain that a trapeze is contraindicated because it promotes twisting.

d.)explain that a trapeze is contraindicated because it promotes twisting.

A client with AD begins to tell the nurse about his early-married life. The nurse should a.)assess orientation to time and place. b.)distract the client from this activity. c.)encourage the client to talk about recent memories. d.)listen to his stories.

d.)listen to his stories.

When the client who has been in flaccid spinal shock dorsiflexes the great toe and fans the other toes when the sole of his foot is stroked, the nurse is a.)alarmed, because this indicates increased ICP. b.)alerted, because this indicates possible meningeal irritation. c.)distressed, because this indicates deterioration. d.)pleased, because this indicates a reduction of spinal shock.

d.)pleased, because this indicates a reduction of spinal shock.

Vital signs on a brain-injured client 1 hour ago were T 98.8° F, P 76, BP . When the nurse takes a current set of vital signs that are T 98.4° F, P 56, BP , the nurse should a.)administer prn pain medications. b.)check the client's blood glucose level. c.)lower the head of the bed. d.)prepare to administer mannitol.

d.)prepare to administer mannitol.

The nurse conducting an admission interview for a client with a herniated lumbar disk would be certain to ask the client about a history of a.)abdominal trauma. b.)developmental problems of the spine. c.)history of meningitis. d.)previous back injury.

d.)previous back injury.

A client's medical record notes a forward slipping of the L5 vertebra. The nurse expects that the diagnosis at the end of the report will state a.)back strain. b.)disk herniation. c.)lordosis. d.)spondylolisthesis.

d.)spondylolisthesis.

When the client complains about having to perform quadricep-setting exercises, the nurse reminds him that the exercises will enhance ambulation by a.)combating footdrop. b.)diminishing the effects of proprioception. c.)improving balance. d.)strengthening the knee.

d.)strengthening the knee.

The nurse explains that the client diagnosed with a spinal tumor will receive a.)radiation and/or chemotherapy. b.)radiation therapy and/or immunotherapy. c.)surgery and/or chemotherapy. d.)surgery and/or radiation therapy.

d.)surgery and/or radiation therapy.