Med- Surge Nuromuscloskeletal

The nurse considers that sensory restriction in a client who is blind can:

1 Increase the use of daydreaming and fantasy

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

1 Administer the prescribed antiemetic

A client has a diagnosis of myasthenia gravis. The nurse recalls that associated clinical manifestations include:

1 Blurred vision along with episodes of vertigo

What should the nurse take into consideration when planning nursing care for a client experiencing an acute episode of rheumatoid arthritis?

2 Bony ankylosis of a joint is irreversible and causes immobility.

A client sustains a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Postoperatively it is most essential for the nurse to:

2 Perform a neurovascular assessment of both lower extremities

A client is recuperating from a spinal cord injury at the T4 level and depends on a wheelchair for mobility. What should the nurse teach the client to prepare for use of a wheelchair?

2 Push-ups to strengthen arm muscles

A client has rotator cuff surgery. What should be included when the nurse performs a neurovascular assessment of the affected extremity immediately after surgery? (Select all that apply.)

2 Skin color 4 Movement of the hand 5 Sensations in the extremity

A nurse is planning to transfer a client who is experiencing pain from the bed to a chair. Place the following steps in the order in which they should be implemented.

2 Verify the client's activity prescription. 1 Identify factors that may impact the ability to transfer. 3 Explain the steps of the transfer. 4 Ensure that the wheels on the bed are locked. 5 Position the client in functional body alignment before transferring

A client with multiple sclerosis is informed that this is a chronic, progressive neurological condition. The client asks the nurse, "Will I experience excruciating pain?" What is the nurse's best response?

3 "Pain is not a characteristic symptom of this disease process."

A client returns from the post-anesthesia care unit after a right rotator cuff repair. What should the nurse do when performing a neurovascular assessment?

3 Assess for capillary refill in the nail beds.

A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? (Select all that apply.)

3 Deep bone pain 5 Depressed deep tendon reflexes

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?

4 Autonomic hyperreflexia

When a client who had an above-the-knee amputation (AKA) complains of phantom limb sensations, the nursing staff should:

4 Describe the neurological mechanisms in language that the client understands

A client who had a brain attack (CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. The nurse documents this response as:

1 Anomia

A client newly diagnosed with rheumatoid arthritis is admitted to the hospital with bilateral painful knee and wrist joints. The nurse identifies impaired physical mobility related to painful, swollen joints. What should the nurse teach the client to do during the acute phase of the disease?

1 Avoid exercises to the involved joints

A client has a diagnosis of trigeminal neuralgia. When assessing the client's trigeminal nerve function, the nurse should evaluate:

1 Corneal sensation

What instructions should the nurse provide to a client after a long leg cast is removed?

1 Elevate the extremity when sitting.

A client diagnosed with bone cancer of the leg will receive radiation therapy as part of the treatment plan. The client has voiced concern about the side effects of the radiation treatments. The nurse will prepare the patient for which major side effects of radiation therapy? (Select all that apply.)

1 Fatigue 5 Altered taste sensations

A client arrives on the nursing unit unconscious and exhibiting decerebrate posturing. When assessing the client, the nurse expects to observe:

1 Hyperextension of both the upper and lower extremities

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson disease. The nurse assesses for which adverse responses that are associated with this medication? (Select all that apply.)

1 Nausea 5 Emotional changes

A client with a history of tuberculosis reports difficulty hearing. Which medication should the nurse consider is related to this response?

1 Streptomycin

The nurse supports cognitive ability in clients with Alzheimer dementia, by: (Select all that apply.)

1 Using calendars, clocks, and pictures to support memory 2 Encouraging caregivers to support protected independence 3 Providing a limited number of choices to support decision making

A client is receiving phenytoin (Dilantin) for a seizure disorder and heparin for a deep vein thrombosis. Warfarin (Coumadin) is added in preparation for discontinuing the heparin. Why must the nurse observe the client closely during the initial days of treatment with warfarin?

1 Warfarin affects the metabolism of phenytoin.

A client who had a tonic-clonic seizure of unknown etiology is to begin taking phenytoin (Dilantin). The nurse should instruct the client to:

2 Brush the teeth and gums three times daily

A client has a decreased serum sodium level. The nurse should assess the client for which signs of hyponatremia? (Select all that apply.)

2 Confusion 5 Muscle weakness

A nurse is caring for a client who had a total hip replacement. What nursing action should be incorporated into the plan of care to prevent thrombus formation?

2 Encouraging the client to perform ankle exercises

A client manifests right-sided hemianopsia as a result of a brain attack (CVA). The nurse develops a plan of care and includes:

2 Instruct the client to scan surroundings

. The nurse teaches a premenopausal obese client about strategies to prevent osteoporosis. Which strategy identified by the client indicates that the teaching is effective

2 Joins a tennis league and practices every day.

To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? (Select all that apply.)

2 Liver 5 shellfish

A nurse is caring for a client who is hospitalized because of injuries sustained in a major automobile collision. As the client is describing the accident to a friend, the client becomes very restless, and his pulse and respirations increase sharply. Which factor probably is related to the client's physical responses?

3 Delayed psychological response to trauma

A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern?

3 Extending

A jogger sustains multiple fractures of the femur after being hit by a motor vehicle. A nurse responds to the scene of the accident to assist with care. The nurse recalls that, for this type of fracture, immediate life-threatening systemic complications can be minimized by:

3 Handling and transporting the client gently

A client is diagnosed with Parkinson disease and receives a prescription for levodopa (L-dopa) therapy. The nurse concludes that the medication is appropriate for this client because it:

3 Restores the dopamine levels in the brain

A nurse raises three of four of the client's bedside rails at night. Which psychosocial outcome does the nurse hope to achieve through the use of side rails?

3 Support a sense of security

A client with chronic osteomyelitis in the leg is scheduled to have a debridement of the infected bone. What should the nurse include in the postoperative plan of care?

4 Inform the client that the leg may be immobilized in a cast or splint

A nurse is caring for a client who just had an above-the-knee amputation. What is the key factor in assessing how the client will cope with the body image change?

4 Personal perception of the change

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. What frequent assessment does the nurse determine is most important for a client with this syndrome?

4 Respiratory exchange

A client with a head injury is admitted to the hospital. Which client response indicates increasing intracranial pressure?

4 Widening pulse pressure