Ch. 64

A patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective?

"I need to allow my arms and hands to support my body weight."

The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse?

"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, would not be manifested by which of the following?

20/20 vision

What diet can the nurse recommend to a patient with hypoproteinemia that spares protein?

A diet high in carbohydrates

An elderly woman diagnosed with osteoarthritis has been referred for care. The client has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention will best promote the client's mobility?

Administer an analgesic as prescribed to facilitate the client's mobility.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?

Alternatively patch one eye every 2 hours.

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply.

Anemia Diaphoresis Edema

A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?

Cerebellar abscess

Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis?

Controlling seizures and increased intracranial pressure

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

Diplopia and ptosis

The rehabilitation nurse is caring for a 25-year-old client who suffered extensive injuries in a motorcycle accident. During each interaction with the client, what action should the nurse perform most frequently?

Evaluate the client's positioning.

The nurse is initiating a bladder-training schedule for a patient. What intervention can be provided for optimal success? (Select all that apply.)

Give up to 3,000 mL of fluid daily. Encourage the patient to wait 30 minutes after drinking a measured amount of fluid before attempting to void. Teach bladder massage to increase intra-abdominal pressure.

Which is the most common cause of acute encephalitis in the United States?

Herpes simplex virus (HSV)

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis?

Neck flexion produces flexion of the knees and hips

A patient diagnosed with multiple sclerosis (MS) has ataxia. Which of the following medications could be used to treat this clinical manifestation?

Neurontin

A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation?

Priority setting is helpful in dealing with the impact of the disability.

A nurse has taught a client how to perform quadriceps-setting exercises. The nurse determines that the client has understood the instructions when he demonstrates which of the following?

Pushes the popliteal area against the mattress while raising the heel

Which of the following is the first-line therapy for myasthenia gravis (MG)?

Pyridostigmine bromide (Mestinon)

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Speeds nerve impulse transmission

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?

Suction machine with catheters

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

A patient learning to ambulate with crutches advances both crutches and then lifts both feet, moving them forward and landing them in front of the crutches. The patient then repeats this motion. The nurse identifies this as which type of crutch gait?

Swing-through

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at

controlling seizures and increased intracranial pressure.

The nurse has developed an evidence-based plan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care?

the patient

A nurse is working with a patient to establish a bowel training program. Based on the nurse's understanding of bowel function, the nurse would suggest planning for bowel evacuation at which time?

After breakfast

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following?

Client does not reach the toilet before experiencing voiding.

The nurse assesses initial skin redness in a patient who is at risk for skin breakdown. How should the nurse document this finding?

Hyperemia

The diagnosis of multiple sclerosis is based on which test?

Magnetic resonance imaging (MRI)

Which nursing intervention is the priority for a client in myasthenic crisis?

Assessing respiratory effort

A client has been transferred to a rehabilitative setting from an acute care unit. What is the most important reason for the nurse to begin a program for activities of daily living (ADLs) as soon as the client is admitted to a rehabilitation facility?

The ability to perform ADLs may be the key to re-entering the community.

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?

The client will remain free of injury if a seizure does occur.

A nurse is assessing a client who will be discharged home after rehabilitation for a stroke. The nurse is questioning the client about his instrumental activities of daily living (IADLs). Which of the following would the nurse address?

Cooking

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule.

Bell's palsy is a paralysis of which of the following cranial nerves?

Facial

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?

Initiate seizure precautions.

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?

The client grasps the affected arm at the wrist and raises it.

The nurse is fitting a patient for crutches that are required for an ankle injury. What quick method can the nurse use to measure so that the crutches will be of appropriate height?

Use the patient's height and subtract 16 inches.

A nurse is reviewing the medical record of an immobilized patient who has developed a pressure ulcer. Which nutritional deficiency would the nurse identify as placing the patient at risk for delayed wound healing?

Vitamin C

A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is given crutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client?

Whether the client needs to navigate stairs routinely at home

The nurse is administering the IV antiviral medication ganciclovir (Cytovene) to the patient with HSV-1 encephalitis. What is the best way for the nurse to administer the medication to avoid crystallization of the medication in the urine?

Administer via slow IV over 1 hour.

A 52-year-old married man with two adolescent children is beginning rehabilitation following a motor vehicle accident. The nurse planning the client's care. Who will the client's condition affect?

Him and his entire family

A college student goes to the infirmary with a fever, headache, and a stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? Select all that apply.

Administration of ceftriaxone sodium Administration of ciprofloxacin hydrochloride Administration of rifampin

Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?

Creutzfeldt-Jakob disease

A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply.

Eating Toileting Bathing

A nurse is assessing a client for potential problems related to function and mobility. Which of the following would alert the nurse to identify a potential problem related to function or movement?

Holds onto the furniture when walking in the house

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?

Moisture

Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?

Positive Brudzinski sign

An adult client's current goals of rehabilitation focus primarily on self-care. What is a priority when teaching a client who has self-care deficits in ADLs?

To provide an optimal learning environment with minimal distractions

A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate?

Treatment with antimicrobial prophylaxis as soon as possible

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?

Trochanter roll

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?

Facial distortion and pain

The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply.)

Have an adequate intake of fiber containing foods. Set a daily defecation time that is within 15 minutes of the same time every day. Have a fluid intake between 2 and 4 L/day.

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?

Positive Brudzinski's sign