exam 3

A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client?

"This is not a stroke, and many clients recover in 3 to 5 weeks."

The nurse has a prescription to administer diazepam 5 mg by the intravenous (IV) route to a client. The nurse would administer the medication over a period of at least how long?

1 minute

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention would be included in the care plan for this client? Select all that apply. 1. Provide oral hygiene after each meal. 2. Assess swallowing ability frequently. 3. Allow the client sufficient time to eat. 4. Maintain a suction machine at the bedside. 5. Provide a full liquid diet for ease in swallowing.

1, 2, 3, 4

The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of Hodgkin's disease. Which assessment findings noted in the client's record are associated with this diagnosis? Select all that apply. 1. Fever 2. Weight loss 3. Night sweats 4. Visual changes 5. Enlarged, painless lymph nodes

1, 2, 3, 5

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week

1, 2, 4

The home health nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals related to decreased muscle strength. Which suggestions would the nurse give to the client? Select all that apply. 1. Chew food thoroughly. 2. Cut food into very small pieces. 3. Lift the head while swallowing liquids. 4. Sit straight up in the chair while eating. 5. Swallow when the chin is tipped slightly downward to the chest.

1, 2, 4, 5

The nurse is caring for the client with a SCI at the level of the sixth cervical vertebra. Which findings support the nurse's conclusion that the client may be experiencing autonomic dysreflexia? Select all that apply 1. Blurred vision 2. BP 198/102 3. HR 150 4. Extreme headache 5. Sweaty face and arms

1, 2, 4, 5

The nurse is evaluating the respiratory outcomes for a client with Guillain-Barré syndrome. The nurse determines that which are acceptable outcomes for the client? Select all that apply. 1. Spontaneous breathing 2. Oxygen saturation of 98% 3. Adventitious breath sounds 4. Normal arterial blood gas levels 5. Vital capacity within normal range.

1, 2, 4, 5

A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the primary health care provider will request which prescriptions? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Decreased oral sodium intake 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone

1, 2, 5, 6

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures would the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent

1, 2, 5, 6

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions would the nurse take? Select all that apply. 1. Loosening restrictive clothing 2. Restraining the client's limbs 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward 5. Keeping the curtain around the client and the room door open so that when help arrives, they can quickly enter to assist

1, 3, 4

A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse would keep which most important items available at the client's bedside?

Ambu bag and suction equipment

The nurse is caring for a client who the physician suspects could have leukemia. The nurse anticipates that the physician will prescribe which of the following to confirm the diagnosis?

Bone marrow biopsy

The nurse is administering medications to a client with trigeminal neuralgia. The nurse expects that which medication will be prescribed for pain relief?

Carbamazepine and gabapentin

The nurse reviews the primary health care provider's (PHCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the PHCP would the nurse question?

Clear liquid diet

The nurse has a prescription to administer phenytoin 100 mg mixed in 5% dextrose in water by the intravenous (IV) route to a client. After reading this prescription, which action would the nurse take?

Contact the primary health care provider (PHCP) to question the prescription.

A client began taking amantadine approximately 2 weeks ago. The nurse determines that the medication is having a therapeutic effect if the client exhibits which finding?

Decreased rigidity and akinesia

A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom?

Difficulty closing the eyelid on the affected side

The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs further teaching if the client states an intention to take which action?

Drink alcohol in small amounts and only on weekends.

A client is receiving phenobarbital sodium. Which finding on the nursing assessment would indicate that the client is experiencing a common side or adverse effect of this medication? 1. Drowsiness 2. Hypocalcemia 3. Blurred vision 4. Seizure activity

Drowsiness

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse would bring which most essential items into the client's room?

Electrocardiographic monitoring electrodes and intubation tray

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action would the nurse take?

Elevate the head of the bed.

The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?

Encouraging fluids

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?

Flaccid paralysis

The nurse has taught a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that further teaching is needed if the client states the need to take which action?

Get out of bed by sitting straight up and swinging the legs over the side of the bed.

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)?

Leaving the client in an unchilled area of the room

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action?

Listen to breath sounds.

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse would instruct the client about the importance of returning to the clinic for monitoring of which laboratory study?

Liver function studies

The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern?

Lung vital capacity of 10 mL/kg

The nurse is monitoring a client with chronic lymphocytic leukemia (CLL). Which sign would the nurse specifically monitor for and report to the primary health care provider?

Lymphadenopathy

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?

Meningitis

The nurse is reviewing the record for a client seen in the health care clinic and notes that the primary health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder would the nurse expect to see documented in the record?

Mild clumsiness

The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition?

Muscle spasm in the area of the herniated disk

The nurse is caring for a client diagnosed with Alzheimer's disease. The nurse would anticipate that the client has changes in which component of the nervous system?

Neuronal dendrites

The nurse is preparing an intravenous (IV) infusion of phenytoin as prescribed by the primary health care provider for the client with seizures. Which solution would the nurse plan to use to dilute this medication?

Normal saline solution

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor?

Omitting doses of medication

A client with myasthenia gravis who is taking neostigmine is experiencing frequent exacerbations of myasthenic crisis and cholinergic crisis. The nurse teaches the client that it is most important that this medication be taken in which manner?

On time

The nurse is caring for a client with bacterial meningitis. The nurse would anticipate that an antibiotic with which characteristics will be prescribed for the client?

One that is able to cross the blood-brain barrier

The clinic nurse is reviewing the record of a client scheduled to be seen in the clinic. The nurse notes that the client is taking selegiline hydrochloride. The nurse suspects that the client has which disorder?

Parkinson's disease

The nurse in a long-term care facility is reviewing the primary health care provider's (PHCP's) prescriptions on an assigned client. The nurse notes that the PHCP prescribed ropinirole hydrochloride. The nurse determines that this medication has been prescribed to treat which condition in the client?

Parkinsonian syndrome

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention?

Place the client in a sitting position.

The nurse is caring for a client with leukemia who is receiving intravenous chemotherapy. The nurse reviews the laboratory results and notes that the white blood cell count is 2000 mm3 (2 × 109/L), the platelet count is 150,000 mm3 (150 × 109/L), the clotting time is 10 minutes, and the ammonia level is 20 mcg/dL (12 mcmol/L). Which nursing action would be appropriate?

Place the client on neutropenic precautions.

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness?

Providing information, giving positive feedback, and encouraging relaxation

The nurse cares for a client immediately following a lumbar laminectomy procedure. The client reports numbness and tingling down the left lateral thigh and knee. What is the next action for the nurse to take?

Question the client about preoperative symptoms.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease?

Respiratory or gastrointestinal infection during the previous month

The nurse is teaching a client with paraplegia from a spinal cord injury measures to maintain skin integrity. Which instruction will be most helpful to the client?

Shift weight every 2 hours while in a wheelchair.

The nurse is caring for a client with Parkinson's disease. Which finding about gait would the nurse expect to note in the client?

Shuffling and propulsive

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure?

Spasms of the entire body

A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse determines that the client's clinical manifestations are due to what type of physiological response?

Sympathetic nervous system

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?

Taking medications as scheduled

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The oncology nurse specialist provides an educational session for nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further teaching is needed if a nursing staff member states that which is a characteristic of the disease?

The disease occurs most often in those older than 75 years of age.

The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information would the nurse include in the teaching plan?

There is the potential of decreased effectiveness of birth control pills while taking phenytoin.

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The client asks for a snack and something to drink. The nurse would plan to offer which best snack to the client?

Vanilla wafers and room-temperature water

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication?

White blood cell count, 3000 mm3 (3.0 × 109/L)

The nurse is caring for a client diagnosed with bacterial meningitis. Which clinical manifestation would the nurse monitor for, indicating increased intracranial pressure?

Altered mental status

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?

Increased calcium level

The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which assessment question?

"Are you getting up at night to urinate?"

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement?

"Going to the beach will be a nice, relaxing form of activity."

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching?

"I can change the time of my medication on the mornings when I feel strong."

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?

"I don't need to use my walker to get to the bathroom."

The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs further teaching if the client makes which statements?

"I will expose my face to cold to decrease the pain."

A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the side and adverse effects of the medication. Which client statement indicates an understanding of the side and adverse effects of the medication?

"I will report a fever or sore throat to my doctor."

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?

"I'll try to eat my food either very warm or very cold."

The nurse is caring for a client with myasthenia gravis who has received edrophonium by the intravenous route to test for myasthenic crisis. The client asks the nurse how long the improvement in muscle strength will last. Which response would the nurse make to the client?

"It will last for 4 to 5 minutes."

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. 1. Postictal status 2. Duration of the seizure 3. Changes in pupil size or eye deviation 4. Seizure progression and type of movements 5. What the client ate in the 2 hours preceding seizure activity

1, 2, 3, 4

A client with leukemia is receiving busulfan and allopurinol. The nurse would plan to tell the client that the purpose of the allopurinol is to prevent which problem?

High uric acid levels

The nurse in the primary health care provider's office is reviewing the results of a client's phenytoin level determination performed that morning. The nurse identifies that a therapeutic medication level has been achieved if which result is noted?

15 mcg/mL (59.52 mmol/L)

A client with Parkinson's disease has begun therapy with levodopa/carbidopa. The nurse determines that the client understands the action of the medication if he or she verbalizes that results may not be apparent for approximately how long?

2 to 3 weeks

A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse would include which interventions in the plan of care to maintain client safety after this procedure? Select all that apply. 1. Use the overhead trapeze. 2. Keep the head of the bed flat. 3. Place pillows under the length of the legs. 4. Use a logrolling technique for repositioning. 5. Assist the client with eating meals and drinking fluids.

2, 3, 4, 5

The primary health care provider is preparing to administer edrophonium to the client with myasthenia gravis. In planning care, the nurse understands which about the administration of edrophonium? Select all that apply. 1. Edrophonium is a long-acting cholinesterase inhibitor. 2. Atropine is used to reverse the effects of edrophonium. 3. If symptoms worsen following administration of edrophonium, the crisis is cholinergic. 4. Edrophonium is used to distinguish between a myasthenic crisis and a cholinergic crisis. 5. An improvement in symptoms following administration of edrophonium indicates myasthenic crisis.

2, 3, 4, 5

A client brought to the emergency department had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what would the nurse include in the client's assessment?

History of prior trauma

Which interventions are the most appropriate for a client who is experiencing thrombocytopenia? Select all that apply. 1. Use a straight-edge razor for shaving. 2. Obtain a rectal temperature every 8 hours. 3. Check secretions for frank or occult blood. 4. Give vitamin K by the intramuscular route. 5. Encourage fluid intake to avoid constipation. 6. Provide oral sponges or a soft toothbrush for oral care.

3, 5, 6

The nurse is caring for a client who is receiving asparaginase. The nurse would monitor the client for improvement of which condition?

Acute lymphocytic leukemia

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem?

Altered breathing pattern

The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client?

400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon

A client with a herniated disk who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to which member of the health care team?

A Social Worker

A client receiving therapy with carbidopa/levodopa is upset and tells the home health nurse that the urine has turned a darker color since starting this medication. The client wants to discontinue its use. In formulating a response to the client's concerns, the nurse interprets that this change is indicative of which condition?

A harmless side effect of the medication

A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis?

A temporary worsening of the condition

The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The primary health care provider gives a test dose of edrophonium. Evaluation of the results indicates that the test is positive. Which would be the expected response noted by the nurse?

An increase in muscle strength within 1 to 3 minutes

A client is suspected of having myasthenia gravis. Edrophonium is administered intravenously to determine the diagnosis. Which indicates that the client may have myasthenia gravis?

An increase in muscle strength within 30 to 60 seconds following administration of the medication

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect?

Impaired voluntary movements

The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest in Williams' position to minimize the pain. The nurse would put the bed in what position?

In semi-Fowler's position, with the knees slightly flexed

The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and would tell the spouse to report which side effect if it occurs?

Inability to urinate

The nurse is assisting in the care of a client with myasthenia gravis who is receiving pyridostigmine. Which medication would the nurse plan to have readily available should the client develop cholinergic crisis because of excessive medication dosage?

Atropine sulfate

The nurse who is caring for a client with myasthenia gravis is told by the physician that an edrophonium test will be done. After obtaining edrophonium the nurse would be certain that which also is available at the bedside?

Atropine sulfate

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What would the nurse immediately suspect?

Autonomic dysreflexia (hyperreflexia)

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. The nurse would expect to note documentation of which early symptom of this disease?

Balance and coordination problems

A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, would the nurse identify as being unrelated to the exacerbation?

Ingestion of increased fruits and vegetables

The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action?

Initiating a bowel movement every other day, 45 minutes after the largest meal of the day

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding?

Ipsilateral paralysis and loss of touch and vibration

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action?

Placing the client on a bed that provides spinal immobilization

The nurse is reviewing the medical record for a client who has been diagnosed with Hodgkin's disease. The nurse would check which diagnostic test noted in the client's record to determine the stage of the disease?

Positron emission topography (PET) scan

The nurse is preparing to ambulate a client with Parkinson's disease who has recently been started on levodopa/carbidopa. Before performing this activity with the client, the nurse would include which most important assessment in the client's plan of care?

Postural (orthostatic) vital signs

The nurse is monitoring a client with acute lymphocytic leukemia for toxic effects of asparaginase. The nurse would notify the primary health care provider if monitoring reveals which finding?

Prolonged blood clotting times

The nurse is preparing to care for a client with suspected meningitis after a lumbar puncture. The nurse would plan to place the client in which best position following the procedure?

Prone with a small pillow under the abdomen