Exam 3

B. Tremors decrease in severity when attention is diverted by activity. Rationale: Clients with a diagnosis of Parkinson disease usually only exhibit tremors at rest, If the client is given an activity to perform, the tremors seem to go away as the client pursues the purposeful activity due to the diversion.

A client diagnosed with Parkinson disease has tremors of both upper arms. The nurse observes that the tremors disappear as the client unbuttons the shirt. Which statement indicates the most accurate understanding of the tremors? A. Tremors are physiological and can be controlled at will. B. Tremors decrease in severity when attention is diverted by activity. C. Tremors are unexplainable and may increase with medication. D. Tremors disappear with rest and increase with any activity.

D. Monitor the client for brief interruptions of consciousness. Rationale: Typical absence seizures are characterized by a monetary episode of loss of consciousness. The client may have a blank stare for a few seconds, or may stop talking in the middle of a sentence. After the seizure, the client is usually unaware that consciousness has been lost.

A client diagnosed with typical absence seizures. It is most important for the nurse to take which action? A. Place the client incomplete bedrest B. Pad the side rails of the client's bed C. Observe for autonomic, purposeless motions with intense emotional experiences D. Monitor the client for brief interruptions of consciousness

A. Immediately report this finding to the health care provider. Rationale: This finding indicates Brudzinski sign, one of the clinical bedside tests which indicates increased tension in the spinal cord for a client with meningitis. Other signs or symptoms of meningitis include headache, fever, photophobia, changes in LOC, and nuchal rigidity. Kernig sign is another bedside test used to indicate meningeal irritation. Positive Kernig sign is exhibited when the client's hip is flexed to 90 degrees and complete extension of the client's knee is restricted and painful.

A client has a diagnosis of meningitis. The nurse assesses the client. The nurse notes that when the client flexes the head, the client also flexes the hip and knee. Which nursing action is best? A. Immediately report this finding to the health care provider. B. Document finding and continue with nursing assessment. C. Give 10 mg of morphine sulfate for the pain. D. Place the client in high Fowler's position and start O2 at 2 liters.

C. Maintain respiratory function. Rationale: Because of acetylcholine deficiency in myasthenia graves, the conduction of nerve impulses is either limited or blocked at the myoneural junction. This lack of available acetylcholine results in easy fatigue and muscle weakness, especially with muscles engaging in repetitive action. Breathing is a constant, repetitive activity; weakness of the respiratory muscles could lead to a respiratory arrest if untreated.

A client is admitted to the hospital with a diagnosis of myasthenia graves. When caring for this client, the nurse gives priority to which nursing goal? A. Provide meticulous personal hygiene. B. Maintain balance between activity and rest. C. Maintain respiratory function. D. Promote adequate hydration.

B. Unusual sensations prior to the seizure. Rationale: An aura can be described as a series of unusual sensations that occur in about 50% of all seizure clients and usually include change in sensation or in affect. The exact character of the aura varied from person to person, but may include numbness, flashing lights, dizziness, smells, and spots before the eyes.

A client is diagnosed with tonic-clonic seizures. The nurse tires to identify the client's aura Which statement accurately describes an aura? A. A state of consciousness during the seizure B. Unusual sensations prior to the seizure C. Emotional status of the client after the seizure D. Uncomfortable feeling as the seizure begins to subside

A. Encourage the client to discuss the "mixed-up" feelings. Rationale: Sensory deprivation occurs in institutionalized clients because of an inadequate quality or quantity of stimulation. The nurse should help a person in this situation relax that it is a temporary problem that is being experienced, caused by sensory deprivation.

An older adult client is in a long-time care facility. The client says, "I know my children visited me today, but they deny it. What's going on? I'm so mixed-up." The nurse suspects this is due to sensory alterations. Which action by the nurse is best? A. Encourage the client to discuss the "mixed-up" feelings. B. Explain to the client the children did not visit. C. Encourage the client's children to visit more frequently. D. Explain that being "mixed-up" doesn't matter.

B. Assess the family support system Rationale: Assessing the family support system is critical in identifying appropriate support persons for a client who is isolated while hospitalized. Part of the nurse's role is to schedule consistent staff contact and encourage visitors to decrease isolation and enhance sensory stimulation.

An older adult is admitted with a diagnosis of acute pulmonary edema. Which is the best intervention for the nurse to include to prevent sensory deprivation? A. Determine the client's hobbies B. Assess the family support system C. Ensure the client can operate the tv D. List the client's ADLs

A. Helps the client back to bed and places a pillow on either side of the client's head. Rationale: An acute attack of vertigo for a client diagnosed with Ménière disease feels like the room is violently spinning. Vertigo and dizziness may cause the client to fall. Lying down will prevent injury and placing pillows on either side of the head will prevent movement of the head, with aggravates vertigo.

The nurse discovers a client diagnosed with Ménière disease leaning over the sink in the room and clutching it with both hands. After determining the client is having an acute attack, which action does the nurse take first? A. Helps the client back to bed and places a pillow on either side of the clients head. B. Lays the client on the floor by the sink and obtains VS and assesses pupillary response to light. C. Gives the client an emesis basin and massages the neck over the area of the carotid arteries. D. Notifies the health care provider and prepares to administer atropine SubQ.

B. The client with clear fluid draining from the right ear. Rationale: Clear fluid from the ears could be a sign of a basilar skull fracture. A basilar skull fracture is a break of a bone in the base of the skull (due to blunt force trauma). Symptoms may include bruising behind the ears, bruising around the eyes, or blood behind the ear drum. A CSF leak may occur and can result in fluid leaking from the nose or ear.

The nurse in the ED admits a client from a multi-car accident. Which client does the nurse attend to first? A. The client with a 2-inch-long laceration on the arm B. The client with clear fluid draining from the right ear C. The client with a hematoma on the forehead D. The client whose pupils are equal and reactive to light

A. "I drink hot coffee with breakfast and after dinner." Rationale: The trigeminal nerve carries sensation from the face to the brain. Hot foods can trigger a pain episode. Instruct the client to avoid foods that are too hot or too cold.

The nurse in the outpatient clinic assesses a client diagnosed with trigeminal neuralgia.The nurse intervenes if the client makes which statement? A. "I drink hot coffee with breakfast and after dinner." B. "I like to eat creamed soups at room temp." C. "I can't wait to eat my spouse's homemade applesauce." D. "I drink tomato juice during my afternoon break."

C. "Apply an eye shield over the affected eye." Rationale: In Bell palsy, the client may be unable to close the eye on the affected side of the face. Corneal abrasion can occur and can cause pain and blindness. Teaching the client to apply an eye shield over the affected eye at night will prevent this occurrence.

The nurse instructs a client diagnosed with Bell palsy. It is most important for the nurse to make which statement about nighttime care? A. "Place a warm compress on the affected side." B. "Perform facial isometrics before you go to bed." C. "Apply an eye shield over the affected eye." D. "Massage your face with an oil-based lotion."

A. The client is placed in the Trendelenburg position. Rationale: A client with a possible head injury are treated as if they also have a spinal cord injury. Until x-rays are completed and the client is cleared of spinal injury, the client's neck should be immobilized and the client should be placed in a supine position.

The nurse provides care for a client admitted to the ED following an automobile accident. The client reports dizziness, and the health care provider suspects a head injury. The nurse intervenes if which activity is observed? A. The client is placed in the Trendelenburg position. B. The client's neck is immobilized prior to being x-rayed. C. The nursing staff frequently monitors the client's LOC D. The nursing staff observes for seizures.

A. The nurse obtains VS and assists the client with morning care in one visit. Rationale: The nurse should combine activities none visit to prevent the client from becoming overly fatigues. The nurse should also schedule uninterrupted time for rest and quiet.

The nurse provides care for a client admitted to the med/surg unit diagnosed with a stroke. The nurse plans care to prevent the client from experiencing sensory overload. The nurse determines which plan is most effective? A. The nurse obtains VS and assists the client with morning care in one visit B. The nurse obtains VS, and completes morning care 2 hours later. C. The nurse completes morning care and schedules PT to follow immediately D. The nurse instructs the family to visit the client every other day.

B. Vertigo, hearing loss, tinnitus Rationale: Ménière disease is an inner ear disorder characterized by vertigo, tinnitus, and fluctuating hearing loss. The client experiences sudden, sever attacks of vertigo with nausea, vomiting, sweating, and pallor. Attacks may be preceded by a sense of fullness in the ear and muffled hearing. Attacks may last hours to days. Usually, only one ear is affected.

The nurse provides care for a client diagnosed with Ménière disease. The nurse expects the client to exhibit which symptoms? A. Dizziness, irritability, weight loss B. Vertigo, hearing loss, tinnitus C. Ringing in ears, ear pain, insomnia D. Nausea, vomiting, hypotension

B. Instruct client to exhale when turning or moving in bed. Rationale: The nurse should instruct the client to avoid any movements or positions which increase intracranial pressure. When the client performs Valsalva maneuver, intracranial pressure is elevated. The client should exhale when moving or turning, avoid straining with stool, or bearing down. The nurse should administer stool softeners.

The nurse provides care for a client diagnosed with a closed skull head injury and increase intracranial pressure. Which action by the nurse is best? A. Position client with HOB flat and client's head in a neutral position B. Instruct the client to exhale when turning or moving in bed C. Encourage client to cough and deep breathe every two hours. D. Suction client frequently and hyper-oxygenate prior to suctioning

D. Checks the indwelling urinary catheter and tubing for kinks. Rationale: Presence of an indwelling urinary catheter can cause stimulation of the bladder and trigger autonomic dysreflexia (AD) for the client with a high level spinal cord injury. If no indwelling urinary catheter is present, the nurse should check for bladder distention and catheterize immediately. Urinary tract infection may also precipitate an episode of AD.

The nurse provides care for a client diagnosed with a spinal cord injury at the level of T-3. The client reports pounding headache and nasal congestion. The nurse notes the client has profuse sweating from the forehead and piloerection. Which action does the nurse take first? A. Administer an analgesic to relieve the headache. B. Places the client in Trendelenburg position. C. Administers a prescribed stool softener. D. Checks the indwelling urinary catheter and tubing for kinks.

B. "The procedure is not painful but you must lie still." Rationale: Although an EEG is painless, the client has to remain still for the duration of the test. The client should also be instructed to bathe the entire Boyd and wash the hair prior to the procedure. The client should not use gels, lotions, oils, or hairsprays.

The nurse provides care for a client scheduled for electroencephalogram (EEG). To prepare the client for the test, it is most important for the nurse to make which statement? A. "The test lasts for approx. 2-3 minutes." B. "The procedure is not painful but you must lie still." C. "The wires cause brief electrical shocks." D. "After the test, you should stay in bed for 8 hours."

B. "Have you experienced this sensation before?" Rationale: The nurse should suspect the client is describing an olfactory aura and explore any details about the occurrence. Although uncommon, olfactory auras are associated with temporal lobe epilepsy. The aura represents the local signature of the attack, and is the result of abnormal stimulation of the cortical area.

The nurse provides care for a client suspected of having a seizure disorder. The client tells the nurse, "I smelled oranges today and there wasn't one on my tray." Which response by the nurse is best? A. "If you would like an orange I'll get you one from the kitchen." B. "Have you experienced this sensation before?" C. "Why do you think you're thinking about oranges?" D. "Isn't that strange? Maybe it's someone's cologne."

A. To prevent corneal irritation. Rationale: The Glascow coma scale is based on a 15 point scale which measures motor response, verbal response, verbal response, and eye opening. A score of 7 or less on the Glascow coma scale indicates severe TBI with coma. When the client is comatose, the eyes may stay partially open causing the corneas to dry out and become irritated. Preventative care involves keeping the corneas moist by using artificial tears. If the corneal reflex is absent, a protective shield should be put over the eyes to prevent abrasion to the corneas.

The nurse provides care for a client with a diagnosis of TBI. The client has a score of 7 on the Glascow Coma Scale. The nurse identifies it is important to give eye care to this client for which reason? A. To prevent corneal irritation. B. To suppress inflammation of the conjunctiva. C. To promote lacrimal drainage. D. To inhibit bacterial growth.

B. Checks the nasal drainage for glucose. Rationale: A badilar skull fracture or penetrating injury can cause leakage of cerebrospinal fluid form the nose and/or ears. The nurse should assess the ears and nose for clear drainage and if any is present, the drainage should be tested immediately. Cerebrospinal fluid tests positive for glucose.

The nurse provides care for a newly admitted client diagnosed with a head injury. The nurse notes the client has clear nasal drainage. Which action does the nurse take first? A. Obtains a specimen of the fluid for culture and sensitivity. B. Checks the nasal drainage for glucose. C. Obtains the client's temperature. D. Instructs the client to blow nose.

A. "I will buy lots of broth and soup for my parent." Rationale: This statement would indicate the family member does not understand the disease process. The client with a diagnosis of Parkinson disease may have difficulty with the sequence of swallowing and be at high risk for choking. The family member should offer a diet of semi-solids with thickened liquids. The client should sit in an upright position when eating and be encourage to think through the sequence involved in swallowing.

The nurse provides education to the family member of a client diagnosed with Parkinson disease. Which statement by the family member reflects a need for further education? A. "I will buy lots of broth and soup for my parent." B. "I am teaching my parent posture exercises." C. "My parent is going to do the rang-of-motions exercises 3 times a day." D. The bath bars will be installed before my parent comes home."

B. Trigeminal Rationale: The trigeminal nerve is cranial nerve V and controls jaw movement and sensation of the face and neck.Tic douloureux (trigeminal neuralgia) usually causes sudden, usually unilateral, severe, stabbing and recurrent episodes of facial pain. It occurs approx. twice as often in women as in men and mostly in people over 50 years of age.

The nurse understands which cranial nerve is affected in tic douloureux? A. Optic B. Trigeminal C. Facial D. Vagus

B. Maintain optimal function with the client's limitations. Rationale: Parkinson disease is an irreversible and degenerative neurological disease that leads to permanent physical limitations. The most appropriate and realistic goal is to assist the client to maintain optimal functioning within the limitations of the disease process.

Which nursing goal is most realistic and appropriate in planning care for a client diagnosed with Parkinson disease? A. Return the client to usual activities of daily living. B. Maintain optimal function within the client's limitations. C. Prepare the client for a peaceful and dignified death. D. Arrest progression of the disease process in the client.

D. Eases the client to the floor. Rationale: The client should be eased to the floor at the onset of the seizure. One of the primary goals of a nurse caring for a client who is having a seizure is to protect the client from injury. If the client is in an upright position when a generalized seizure begins, the client should be lowered to the floor, and adjacent articles and equipment should be moved to prevent injury.

While the nurse ambulates the client to the bathroom, the client begins to have a seizure. Which action does the nurse take first? A. Notes the time the seizure began. B. Carries the client to the nearest bed. C. Calls for a wheelchair. D. Eases the client to the floor.