ATI quiz 8

a nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self catheterization at home after discharge. which of the following statements indicates that the client understands the procedure?

I will perform intermittent self catheterization every 2 - 3 hrs

a nurse is providing teaching to a client who has a new diagnosis of MS. the client asks the nurse about the usual cause of MS. which of the following responses should the nurse make?

acute episodes are usually followed by remissions, which can vary in duration

a nurse is preparing a client for an EEG. when the client asks the nurse what this test does, which of the following responses should the nurse provide?

an EEG records the electrical activity of your brain cells

a nurse is caring for a client who has received sedation. when the nurse applies nailbed pressure, the client withdraws his hand. the nurse should document this response as indicating which of the following

arousal

a nurse responds to a call from an assistive personnel that a client just had a seizure and is unconscious. which of the following assessments is the nurse's priority?

check airway patency

a nurse is preforming a neurological assessment for a client. by asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?

cranial nerve XII

a nurse is preparing a client who has a brain tumor for CT. which. of the following factors affects the manner in which the nurse will prepare the client for the scan?

development of hives when eating shrimp

a nurse is preparing to test the function of cranial nerve X. which of the following assessments should the nurse use?

have the client open his mouth and say "ah"

a nurse is caring for a client who is wearing a halo fixator. which of the following interventions should the nurse implement?

monitor the client's vital signs every 4 hr monitor the client's pin sites for loosening check the client's skin to ensure the jacket is not applying pressure

a nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. which of the following supplies should the nurse place at the client's bedside?

oral-nasal suction equipment

a nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. after checking the client's vital signs, which of the following actions should the nurse perform next?

place the client in a high-fowler's position

a nurse is caring for a client who has impairment of cranial nerve II. which of the following actions should the nurse perform to promote the client's safety?

provide an obstacle-free path for ambulation

an emergency room nurse is assessing a client who has a new traumatic brain injury, the nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. which of the following actions is the nurse's priority?

provide supplemental oxygen

a nurse is assessing a client who has a high-thoracic spinal injury. the nurse should identify which of the following findings as a manifestation of autonomic dysreflexia?

reports of a headache

a nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination. which of the following pieces of information in the client's history is a contraindication to this procedure?

the client has a pacemaker

a nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. which of the following reactions should the nurse anticipate when drawing a blood sample?

the client rigidly extends his arms

a nurse is caring for a client who is recovering from a recent stroke. which of the following assessments is the nurse priority?

the client's ability to clear oral secretions

a nurse in the emergency department is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. which of the following clients should the nurse assess first?

a client who is difficult to arouse and is unable to respond to questions

a nurse is assessing a client who has a head injury with a possible skull fracture. which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve?

dizziness and hearing loss

a nurse is teaching a client who will be taking dexamethasone daily for pain due to spinal edema. the nurse should identify which of the following client statements as an indication that the teaching has been effective?

i should stay away from people who are ill

a nurse in the emergency department has assessed a client's ABC following a head injury from a fall at work. which of the following actions is priority for the nurse to perform next?

immobilize the client's cervical spine

a nurse is assessing a client who has increased intracranial pressure and has received intravenous mannitol. which of the following findings indicates a therapeutic effect of this medication?

increased urine output

a nurse is caring for a client who is postoperative following a lumbar disk excision. which of the following interventions should the nurse include in the client's plan of care?

logroll the client in bed for care procedures

a nurse is caring for a client who has cancer involving the lumbar vertebrae and has been prescribed gabapentin. which of the following therapeutic effects should the nurse identify for the client when taking this medication?

reduced cramping, aching, and burning neuropathic pain

a nurse is caring for a client who begins to have a generalized tonic-clonic seizure while lying in bed. which of the following actions should the nurse take?

turn the client onto a side

a nurse is assessing a client who has Guillian Barre syndrome. which of the following findings should the nurse expect?

weakness of the lower extremities

a nurse is assessing a client who sustained a recent head injury. which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?

widened pulse pressure

a nurse is providing teaching to a client who has multiple sclerosis and a new prescription for baclofen PO. which of the following pieces of information should the nurse include?

you should change positions slowly while taking this medication

a nurse is teaching a client about CT scanning of the brain. which of the following teaching points should the nurse include?

you'll have to lie very still on a long, narrow table during the test