PCC2 Exam 3 Questions

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

A reddened area over the sacrum

A nurse notes increasing edema in the calf of a client who has multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications?

Acute compliant syndrome

A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?

Apply a protective boot to the right ankle.

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication?

Ask the client to take a few sips of water.

A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first?

Checking capillary refill

A nurse is caring for a client in the emergency department who had a traumatic amputation of his left arm in an industrial accident. The nurse should expect the client to be experiencing which of the following of Kubler-Ross's stages of grief?

Denial

A nurse is teaching a client who taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects?

Difficulty voiding

A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching?

Dry the prosthesis socket completely before applying it to the limb.

Stroke CS: The spouse of a client brought to the ED reports that 6 hours ago, her husband began having difficulty finding words. The client has since become progressively worse. Upon assessment, you note right hemiparesis and urine incontinence. Which of the following is the priority nursing intervention for this client at this time?

Elevate the head of the bed.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

Encourage the client to take small bites.

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Establish the ability to communicate effectively.

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client?

Levodopa/carbidopa

The client is admitted to the acute medical unit. The client's wife must leave her husband's bedside for 2 hours to run errands. Which nursing action is appropriate to contribute to client safety while she is gone?

Maintain the bed in a low position

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Manifestations preceded by a severe headache

A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur. Which of the following interventions should the nurse include in the plan?

Monitor the client's pedal pulses every hour.

An hour later after a CT scan, the client is diagnosed with a left hemisphere stroke. Which assessment findings does the nurse anticipate? (Select all that apply.)

Right visual field deficit Right sided paralysis Aphasia

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?

Surgeon

A nurse in an urgent care center is caring for a client who has a greenstick fracture of the forearm. The nurse should explain that which of the following injuries has occurred with a greenstick fracture?

The bone is cracked lengthwise but did not break all the way through.

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

The client develops a life-threatening situation.

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?

This service began with the client's admission to the hospital.

A nurse is preparing a client who is postoperative following a below-the knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?

Wrap the residual limb with an elastic bandage in a figure eight configuration.

A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures?

Your pain will gradually become less severe

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?

"Implement a schedule to include periods of rest."

A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

"Incorporate nonverbal cues in the conversation."

A nurse is caring for a client who is 2 days postoperative following an above-the knee-amputation. Which of the following is an appropriate nursing intervention for this client at this time?

Have the client lie prone every 3 hours for 20 minute at a time.

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Inability to recognize his family members

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?

Increased respiratory rate of 18 to 44/min.

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first?

Pallor of the toes.

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?

Prepare the client for mechanical ventilation.

A nurse is assessing a client who is postoperative following a right below-the-knee amputation. Which of the following findings should the nurse identify as a possible complication?

Presence edema above the stump dressing

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Provide client supervision

A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching?

Race

A nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. Which of the following instructions should the nurse include in the teaching?

Report any worsening or unrelieved pain

Musc ATI: A nurse is providing teaching for a client who is postoperative following below-the-knee amputation. The nurse should instruct the client that which of the following nutrients is necessary for would healing?

Vitamin C

A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?

Fat embolism

A nurse is teaching a client who has multiple sclerosis about a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching?

"Do not take antihistamines with this medication."

A nurse is teaching a client who has multiple sclerosis and a new prescription for dantrolene. Which of the following statements by the client indicates an understanding of the teaching?

"I need to apply a sunscreen when I go outside."

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?

Buck's extension traction will relieve muscle spasms.

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

Comminuted

The client is admitted to the acute medical unit after 7 hours. His wife asks if her husband will receive IV fibrinolytic therapy. What is the appropriate nursing response?

Fibrinolytic agents must be administered within 3 to 4.5 hours of symptom onset

A client who has a femur fracture states, "I can't stay in this bed any longer. I need to get home so I can take care of my family." The nurse responds, "You have talked about your family several times. Can you tell me more about your specific concerns?" Which type of therapeutic communication response is the nurse using?

Focusing

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

Increasing edema

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Instruct the client to wiggle his toes.

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?

Intellectual impairment

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

Perform neurovascular checks of the extremities.

A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication?

Pitting edema around the stump dressing

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Poor impulse control

Neuro ATI: A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Weakness