ATI Neuro/Musculoskeletal Focused

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? Check the client's cheek on his affected side after eating to be sure no food remains there. Encourage the client to sit upright with his head tilted slightly forward during meals. Provide the client with eating utensils that have large handles. Remind the client to look consciously at both sides of his meal tray.

Homonymous hemianopsia does not cause the client to pocket food. Homonymous hemianopsia does not cause dysphagia. Homonymous hemianopsia does not impair the client's fine motor skills. The client who has right-sided homonymous hemianopsia has lost the right visual field of both eyes and might only eat the food he is able to see on the left half of the meal tray. Therefore, the nurse should remind the client to look consciously at both sides of his meal tray to compensate for the visual loss.

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 35 mm Hg. The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at approximately 35 mm Hg to prevent hypercarbia and subsequent vasodilation effects that lead to increase in intracranial pressure.

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. What action is the nurse's priority?

The first action the nurse should take using the nursing process is to assess the client. The Tensilon test will determine if the client is experiencing a myasthenic crisis or a cholinergic crisis.

A nurse is caring for a client who has a full arm cast and reports pain of 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? Administer additional pain medication. Check the circulation of the affected extremity. Document the findings. Reposition the affected extremity.

The greatest risk to the client is neuromuscular injury resulting from compartment syndrome. The first action the nurse should take is to check for impaired circulation of the affected extremity. Check the circulation of the affected extremity.

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. What action should the nurse take to help stimulate micturition?

The nurse can stimulate micturition by stroking the client's inner thigh.

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. What should the nurse administer?

The nurse should administer osmotic diuretics to rapidly reduce intraocular pressure and prevent damage to the eye.

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. What action should the nurse take first?

These assessment findings indicate the client is at greatest risk for autonomic dysreflexia and 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 caring for a client who is 8 hr postoperative following a craniotomy. Which of the following actions should the nurse take?

1) Suctioning can increase intracranial pressure. Therefore, the nurse should only suction the client when necessary. 2) Following a craniotomy, the client is at risk for hemorrhage and hypovolemic shock. The nurse should report wound drainage greater than 50 mL/8 hr. 3) Following a craniotomy, the client is at risk for increased intracranial pressure. For supratentorial surgery, the nurse should elevate the client's head to 30° and keep it in a neutral position to promote venous drainage. For infratentorial surgery, the nurse should place the head of the bed flat and turn the client onto either side. 4) The nurse should assess the client's neurologic status every 15 to 30 min for 4 to 6 hr following surgery and then every hour. After 24 hr, the provider may decrease the checks to every 2 to 4 hr.