ATI - Musculoskeletal/Neuro CV

A nurse is caring for a client in balanced suspension skeletal traction who reports intermittent muscle spasms. Which of the following actions should the nurse take first?

Check the position of the weights and ropes

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?

Clear drainage from the nose

A nurse is performing a pain assessment on a postoperative client. Which of the following should the nurse use to determine the severity of the client's pain?

Client's report of pain on a standardized pain scale

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect? (Select all that apply)

Crepitus with joint movement Decreased range of motion of the affected joint Joint pain that resolves with rest

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include?

Ensure the client lies flat for up to 12 hours -The client should lie flat for up to 12 hr to prevent cerebrospinal fluid leakage from the puncture site, which can cause a headache. -instruct the client to report complications of a lumber puncture such as voiding difficulties, fever, stiffness of the back or neck, nausea, and vomiting. -hould increase fluid intake to replace the cerebrospinal fluid the provider removed during the procedure. -should apply pressure to the site and then apply an adhesive bandage, not a pressure dressing.

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take?

Establish IV access

A nurse is caring for a client who has a retinal detachment. Which of the following reports about the affected eye should the nurse expect?

Flashes of bright light R: The nurse should expect a client who has a retinal detachment to see flashes of bright light or floating dark spots in the affected eye as the retinal layers separate.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

Impulsive behavior

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority?

Maintain a PaCO2 of approximately 35mm Hg R: The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority intervention is to maintain the PaCO2 at 35 to 38 mm Hg to prevent hypercarbia and subsequent vasodilation that can lead to an increase in intracranial pressure.

A nurse is caring for a client who has advancing amyotrophc lateral sclerosis. Which of the following interventions is the nurse's priority?

Monitor pulse oximetry findings R: he greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor the client's oxygen saturation to identify respiratory compromise as soon as possible.

A nurse in the emergency department is assessing a client who reports sudden, severe eye pain with blurred vision. The provider determines the client has primary angle-closure glaucoma. Which of the following medications should the nurse administer?

Osmotic diuretics via IV bolus

One hour after application of a cast for an ulnar fracture, a client reports a pain level of 8 on a scale from 0-10 that is unrelieved by analgesics and the application of a cold pack. The client's fingers are pale and numb. Based on the client's report which of the following actions should the nurse take first?

Report the findings to the primary care provider

A nurse is caring for a client who is 8 hours postoperative following a craniotomy. Which of the following actions should the nurse take?

Report wound drainage greater than 50 mL/8hrs

A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure

Restlessness

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition

Stroke the client's inner thigh R: The nurse should stimulate micturition by stroking the client's inner thigh. Other techniques include pinching the skin above the groin and providing digital anal stimulation. -Antispasmodics such as oxybutynin, effective for treating mild spastic bladder problems. -should apply direct pressure over the client's bladder, also known as the Credé maneuver, to express urine from a flaccid bladder -should encourage the client to hold their breath and bear down, also known as the Valsalva maneuver, to express urine from a flaccid bladder.

A nurse is providing teaching for a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?

The nurse should teach the client to sit with the hips at a 90 degree angle or less with the knees slightly lower than the hips to avoid hip dislocation.

A nurse is teaching a client who has osteoporosis and a new script for alendronate. Which of the following information should the nurse include in the teaching?

This medication should be taken before breakfast and in an upright position maintained for 30 minutes. -take alendronate with 240 mL (8 oz) of water, not milk. Foods or beverages containing calcium can reduce medication absorption. -instruct the client to take alendronate first thing in the morning, at least 30 min before other medications. -encourage the client to take vitamin D, which promotes calcium absorption.

A nurse in the emergency department is caring for a client after suddenly losing consciousness and falling in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer?

Tissue plasminogen activator

A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect?

Ulnar deviation -A client who has rheumatoid arthritis can experience inflammation in the hand joints that can make them susceptible to deformity from daily use. Ulnar deviation, or lateral deviation of the fingers, can occur from opening jars and other similar motions. -Rheumatoid arthritis usually occurs bilaterally and symmetrically. Osteoarthritis usually occurs unilaterally. -Compression fractures of the spine are more common in clients who have osteoporosis. -A client who has rheumatoid arthritis will have an increased sedimentation rate due to the body's response to the inflammatory connective tissue disorder.

A nurse is teaching an assistive personnel about care of a client who has had a total hip arthroplasty. Which of the following instructions should the nurse include?

place an abductor pillow between the clients legs when turning the client

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?

Monitor capillary refill at least every 4 hours to monitor for vascular compromise.

A nurse is providing teaching for a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements by the family indicates an understanding of the teaching?

"The drugs used to treat Alzheimer's disease can help delay cognitive changes"

A nurse in the emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images indicates a comminuted fracture.

A. Injury that cause the bone to fragment into several pieces.

a nurse is teaching a client who has multiple sclerosis and has a new prescription for glatirame acetate.

"I will avoid going to the store when it is crowded." R: Clients who are prescribed this medication are instructed to avoid crowds and individuals who have infection.

A nurse in the emergency department is assessing a client who has myasthenia gravis. The client reports recent increasing muscle weakness and the nurse suspects the client is experiencing a myasthenic crisis. Which of the following actions is the nurse's prority?

Assist with Tensilon test

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of instructions?

"I should call my doctor if my vision gets worse"

A nurse is teaching a client who has parkinson;s disease about taking carbidopa-levodopa. Which of the following client statements indicates an understanding of the teaching?

-I should expect that this medication can cause me to be drowsy." -Drowsiness is a known adverse effect of carbidopa-levodopa; therefore, clients are taught to avoid heavy machinery and driving if they experience drowsiness. -inform the client that the medication can take 2 to 3 months to take effect. --I should expect my urine to be a darker color" -should be administered before meals to increase absorption and transport the medication across the blood-brain barrier. -Orthostatic hypotension is an adverse effect of carbidopa-levodopa.

A nurse is caring for a client who has a full arm cast and reports pain of an 8 on a scale from 0 to 10 that is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

Check the circulation of the affected extremity

A Nurse is caring for a client who is 72 hours postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?

Administer an oral does of gabapentin to the client

A nurse is caring for a client who is postoperative following a craniotomy. Which of the following interventions is the priority action for the nurse to take?

Elevate the head of the bed 30 degrees

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

Intention tremors

A nurse is caring for a client who is admitted with ascending guillain-barre syndrome. The nurse should give priority to which of the following assessment findings?

Presence of adventitious breath sounds

When caring for a client who has multiple sclerosis, the nurse should recognize that this disorder is characterized by:

Remissions and exacerbations

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level CS. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first?

Elevate the head of the client's bed R: These assessment findings indicate that the client is experiencing autonomic dysreflexia and is at greatest risk for possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension.

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include?

Move head slowly to decrease vertigo

A nurse is planning to teach a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the clients medication teaching plan?

Take medications at a consistent time each day to maintain therapeutic blood levels

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt, the nurse should take which of the following actions?

Remind the client to look consciously at both sides of his meal tray