HC3A Unit 3
Which finding does the nurse expect to see when assessing a client diagnosed with Parkinson's disease? A) Shuffling, propulsive gait B) Head thrust back, chin jutting out C) Hyperactive deep tendon reflexes D) Hyperkinesia
A) Shuffling, propulsive gait
Which goal is collaboratively established by the client with Parkinson's disease, the nurse, and the physical therapist? A) To maintain joint flexibility B) To build muscle strength C) To improve muscle endurance D) To reduce ataxia
A) To maintain joint flexibility
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 were thinking about oranges?" D) "Isn't that strange? Maybe it's someone's cologne."
B) "Have you experienced this sensation before?"
The nurse is teaching a client with seizures to recognize an aura. What should the nurse instruct the client to notice as an onset of an aura? A) A postictal state of amnesia B) A hallucination that occurs during a seizure C) A symptom that occurs just before a seizure D) A feeling of relaxation as the seizure begins to subside
C) A symptom that occurs just before a seizure
For which client will the nurse question the prescription of ziconotide for severe persistent back pain? A) Client with sciatic nerve pain B) Client using massage and heat for pain relief C) Client with severe mental health problems D) Client using NSAIDs and acupuncture for pain relief
C) Client with severe mental health problems
When the nurse is taking a history of an adult client who reports acute low back pain (LBP), which question is most likely to identify a causative factor? A) "Have you recently fallen or been lifting heavy objects?" B) "Are you having pain that radiates down your arm?" C) "Do you have a family history of neurologic disorders?" D) "Are you having trouble with walking or maintaining your balance?"
A) "Have you recently fallen or been lifting heavy objects?"
The nurse provides education to the family member of a client diagnosed with Parkinson's 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 the range-of-motion exercises 3 times a day." D) "The bath bars will be installed before my parent comes home."
A) "I will buy lots of broth and soup for my parent."
The nurse instructs a client diagnosed with urolithiasis how to prevent calcium calculi. Which statement indicates teaching is successful? A) "I will drink at least 3000 mL of fluid each day." B) "I will eat 2 servings of meat or cheese per day." C) "I will drink at least two glasses of cranberry juice daily." D) "I will eat a large amount of citrus fruits each day."
A) "I will drink at least 3000 mL of fluid each day."
The nurse understands that which client is most at risk to develop urinary tract calculi? A) Client who is a vegetarian B) Client who consumes a low sodium diet C) Client with polycystic kidney disease D) Client with diabetic nephropathy
A) Client who is a vegetarian Rationale: Consumption of foods high in calcium or oxalate rich foods (soy, tofu, spinach) increases urine alkalinity and the risk of calculi formation
The nurse is assessing a client in the postictal phase of a generalized tonic-clonic seizure. The nurse should expect the client to have which symptom following the seizure? A) Drowsiness B) Inability to move C) Paresthesia D) Hypotension
A) Drowsiness
Which is an expected outcome for a client with Parkinson's disease who has had a pallidotomy? A) Improved functional ability B) Reduced emotional stress C) Increased alertness D) Better appetite
A) Improved functional ability
A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instruction should the nurse include in the client's discharge teaching plan? A) Increase daily fluid intake to at least 2-3 liters B) Strain all urine for one week C) Eliminate dairy products from the diet D) Follow measures to alkalinize the urine
A) Increase daily fluid intake to at least 2-3 liters
In addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. What additional signs should the nurse assess? A) Nephritis B) Referred pain C) Urine retention D) Additional stone formation
A) Nephritis
Which issue does the nurse consider a priority when caring for a client diagnosed with atonic (akinetic) seizures? A) Possibility of injury related to falls B) Limited mobility related to lack of tonicity of muscles C) Confusion related to postictal period D) Organ ischemia related to decreased perfusion
A) Possibility of injury related to falls
Which goal is the priority for a client with a fractured femur who is in traction? A) Prevent effects of immobility while in traction B) Develop skills to cope with prolonged immobility C) Choose appropriate diversional activities during the prolonged recovery D) Adapt to inactivity from the impaired mobility
A) Prevent effects of immobility while in traction
A nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report to primary care provider? A) Purulent drainage from the pin sites on the client's forehead B) Painful pressure injury under the collar C) Inability to move legs or feet D) Oxygen saturation of 95% on room air
A) Purulent drainage from the pin sites on the client's forehead
A pediatric client is diagnosed with a tonic-clonic seizure disorder. The home health nurse intervenes if which finding is observed? A) The parent takes the child's temperature using an oral electric thermometer B) The parent encourages the child to play with boats during bath time C) The child wears a helmet when riding a bicycle D) The child eats peanut butter and jelly sandwiches
A) The parent takes the child's temperature using an oral electric thermometer
A 21-year-old female client takes clonazepam. What should the nurse ask this client about? SATA. A) Seizure activity B) Pregnancy status C) Alcohol use D) Cigarette smoking E) Intake of caffeine and sugary drinks
A, B, C
A client experiences a seizure that is observed by the nurse. What will the nurse document in the client's medical record? SATA. A) Time that the seizure began and ended. B) Whether the seizure was preceded by an aura C) What the client does after the seizure D) How long it takes for the client to return to pre-seizure status E) The drugs that are administered during the seizure
A, B, C, D
Which actions are appropriate for the nurse to perform when caring for a client who is placed in Buck's traction after a hip fracture? SATA. A) Ensuring that the weights never rest on the floor B) Removing the boot or blet every 8 hours to assess skin integrity C) Comparing the amount of weights applied with the amount prescribed D) Removing the weights every 8 hours for 30 minutes to prevent muscle spasms E) Assessing circulation distal to the traction device every hour for the first 24 hours F) Instructing all personnel and visitors to not touch or change the position of the weights
A, B, C, E, F
Which statement by a client with a seizure disorder who has been prescribed topiramate indicates the client has understood the nurse's instruction about this drug? A) "I will take the medicine before going to bed." B) "I will drink 6-8 glasses of water a day." C) "I will eat plenty of fresh fruits." D) "I will take the medicine with a meal or a snack."
B) "I will drink 6-8 glasses of water a day."
The nurse instructs a client receiving phenytoin sodium. The nurse determines further teaching is necessary if the client makes which statement? A) "I should not drink alcohol while taking this medication." B) "If my urine changes color, I should immediately go to the ER." C) "I should avoid activities requiring alertness for the first 3 days that I take this medication." D) "I should not abruptly discontinue this medication."
B) "If my urine changes color, I should immediately go to the ER."
The nurse teaches a client about proper body mechanics. Which client statement indicates to the nurse that the teaching has been successful? A) "It is normal to experience joint degeneration after age 40, and lower back pain will probably happen even if I lift heavy objects the right way." B) "In the future, I will lift heavy objects by bending at the knees and keeping my back straight." C) "I will need to complete weeks of physical therapy before my back will feel better." D) "I should rest in bed for the next 5-7 days before going back to work."
B) "In the future, I will lift heavy objects by bending at the knees and keeping my back straight."
What is the nurse's best response to a client with lower limb amputation who says "I think I am going crazy. I know my foot is gone but I still feel my big toe burning and itching."? A) "Are you sure you were awake? Sometimes people dream this pain as part of hoping that the missing body part will grow back." B) "You are not crazy; many people continue to feel pain and other sensations in a limb that was amputated. How severe is this pain?" C) "This complication is usually seen in a person who has not accepted the fact that the limb is gone. A psychologist can help you cope with this." D) "This problem is very common and although nothing can be done about it, we can give you pain medication for the pain you feel at the surgical site."
B) "You are not crazy; many people continue to feel pain and other sensations in a limb that was amputated. How severe is this pain?"
The nurse provides care for a client in Buck traction. Which is the most important nursing action to maintain effective traction? A) Encourage the client to limit body movements B) Allow weights to hang freely at all times C) Remove weights immediately when client reports discomfort D) Give pain medication regularly
B) Allow weights to hang freely at all times
Which technique does the nurse use to assess a client's report of paresthesia in the lower extremities? A) Use a Doppler to locate the pedal pulse, the dorsalis pedis pulse, and the popliteal pulse B) Ask the client to identify sharp and dull sensations using a paper clip and cotton ball C) Use a reflex hammer to test for deep tendon reflexes D) Ask the client to walk across the room and observe for gait and equilibrium
B) Ask the client to identify sharp and dull sensations using a paper clip and cotton ball
A client diagnosed with a spinal cord injury is treated with halo traction. Which intervention does the nurse include in the client's plan of care? A) Remove the thoroughly clean pins 3 times a day B) Clean pin sites according to institutional policy C) Remove pins and rotate sites every other day D) Perform flexion and extension neck exercises 4 times a day
B) Clean pin sites according to institutional policy
Which nursing goal is most realistic and appropriate in planning care for a client diagnosed with Parkinson's 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
B) Maintain optimal function within the client's limitations
A client is being discharged following an open reduction and internal fixation of the left ankle and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches? A) Use a four-point gait B) Maintain two to three finger widths between the axillary fold and underarm piece grip C) Keep leg dependent when sitting D) Maintain balance by supporting the body's weight on the axillae
B) Maintain two to three finger widths between the axillary fold and underarm piece grip
Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin? A) Take all medication until it's gone B) Notify the HCP if vision changes occur C) Store gabapentin in the refrigerator D) Take a gabapentin with an antacid to protect against ulcers
B) Notify the HCP if vision changes occur
The nurse is assigned to care for a postoperative client who had an open reduction, internal fixation of the right tibia yesterday. The client reports increased right leg pain, numbness, and tingling. What would be the nurse's first action at this time? A) Elevate the surgical leg on a pillow B) Perform a neurovascular assessment C) Administer pain medication D) Call the HCP
B) Perform a neurovascular assessment
A client with Parkinson's disease needs a long time to complete morning care but becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation? A) Tell the client firmly that he or she needs assistance and help with morning care B) Praise the client for the desire to be independent and give extra time and encouragement C) Tell the client that he or she is being unrealistic about their abilities and must accept the fact that he or she needs help D) Suggest to the client to at least modify their morning care routine if he or she insists on self-care
B) Praise the client for the desire to be independent and give extra time and encouragement
The nurse provides care for a client reporting a sudden onset of severe right flank pain. The client is diagnosed with urinary calculi. Which nursing action has the immediate priority? A) Ensuring the client remains NPO B) Relieving pain C) Straining the urine D) Obtaining a mid-stream urine specimen
B) Relieving pain
The nurse observes that when a client with Parkinson's disease unbuttons her shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? A) The tremors are probably psychological and can be controlled at will B) The tremors sometimes disappear with purposeful and voluntary movements C) The tremors disappear when the client's attention is diverted by some activity D) There is no explanation for the observation; it is a chance occurrence
B) The tremors sometimes disappear with purposeful and voluntary movements
At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? A) Early in the morning, when the client's energy level is high B) To coincide with the peak action of drug therapy C) Immediately after a rest period D) When family members will be available
B) To coincide with the peak action of drug therapy
Which nursing assessments indicate classic signs of Parkinson's disease? A) Sweating, bradycardia, and moon face B) Tremors, bradykinesia, and rigidity C) Bulging eyes, rigidity, and dementia D) Numbness, sweating, and emaciation
B) Tremors, bradykinesia, and rigidity
A client is diagnosed with tonic-clonic seizures. The nurse tries 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
B) Unusual sensations prior to the seizure
The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. The nurse should report which finding to the health care provider? A) Temperature 98.8°F B) Urine output: 20 mL/h C) Absence of bowel sounds D) Serosanguineous drainage on the dressing
B) Urine output: 20 mL/h
What is the nurse's best interpretation when a client is admitted with flank pain, and the urine report indicates turbidity, foul odor, rust color, presence of white blood cells as well as bacteria, and microscopic crystals? A) Staghorn calculus with infection B) Urolithiasis and infection C) Pyuria and cystitis D) Dysuria and urinary retention
B) Urolithiasis and infection
A client expresses concern over the presence of external pain and external devices used to manage her fracture and says she wishes it all could have been placed internally so it wouldn't be visible. What advantages will the nurse tell the client that external fixation has over internal fixation of fractures? SATA. A) The risk for infection is reduced B) You lost less blood than you would have with an internal fixation C) This device allows you yo move and walk earlier than an internal device D) You will not need surgery to remove these devices after healing is complete E) Most people have less pain with the external devices that with internal devices F) This device replaces the need for the use of any other device, such as a cast, or a boot later
B, C, D, E
A client had an open reduction internal fixation of the right wrist. What health teaching is appropriate for the nurse to provide for this client before returning home? SATA. A) "Keep the right arm below the level of your heart as often as possible." B) "Use an icepack for the first 24 hours to decrease tissue swelling." C) "Report coolness or discoloration of your right hand to your doctor." D) "Don't place any device under the cast to scratch the skin if it itches." E) "Move the fingers of the right hand frequently to promote blood flow."
B, C, E
The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which action would be most important for the nurse to include in the pretest preparation? A) Ensure adequate fluid intake on the day of the test B) Prepare the client for the possibility of bladder spasms during the test C) Check the client's history for allergy to iodine D) Determine when the client last had a bowel movement
C) Check the client's history for allergy to iodine
What is the most appropriate action for the nurse to take when assessment on a client with external fixation reveals crusts have formed around the pin sites? A) Assessing the client's temperature B) Notifying the surgeon immediately C) Documenting the finding as the only action D) Removing the crusts and culturing the drainage
C) Documenting the finding as the only action Rationale: Drainage of clear fluid (weeping) is expected in the first 72 hours around pin sites. The drainage forms crusts that are believed to protect the site from infection and are not removed.
Which clinical manifestation is a typical reaction to long-term phenytoin sodium therapy? A) Weight gain B) Insomnia C) Excessive growth of gum tissue D) Deteriorating eye sight
C) Excessive growth of gum tissue
The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which topic is most important to include in the plan? A) Maintaining a balanced nutritional diet B) Enhancing the immune system C) Maintaining a safe environment D) Engaging in diversional activity
C) Maintaining a safe environment
Which circumstance does the nurse recognize as creating the greatest risk of recurrent urolithiasis when a client is admitted for an orthopedic procedure? A) Providing milk to the client with every meal tray or snack B) Insertion of an indwelling urinary catheter for the procedure C) Restricting foods and fluids for extended periods of time D) Administering an opioid narcotic drug for the severe pain
C) Restricting foods and fluids for extended periods of time
A client has a leg immobilized in traction. Which observation by the nurse indicates that the client understands actions to take to prevent muscle atrophy? A) The client adducts the affected leg every 2 hours B) The client rolls the affected leg away from the body's midline twice per day C) The client performs isometric exercises to the affected extremity three times per day D) The client asks the nurse to add a 5 lb weight to the traction for 30 min/day
C) The client performs isometric exercises to the affected extremity three times per day
A client is being switched from levodopa (L-dopa) to carbidopa-levodopa. The nurse should monitor for which possible complication during medication changes and dosage adjustment? A) Euphoria B) Jaundice C) Vital sign fluctuation D) Signs and symptoms of diabetes
C) Vital sign fluctuation
Which action will the nurse take to prevent a flexion contracture in a client who is postoperative from an above-the-knee amputation low on the femur? SATA. A) Applying the elastic wraps on the stump distal to proximal in a figure-eight pattern B) Using aseptic technique when irrigating the wound or changing the dressing C) Instructing the client to perform gluteal muscles contraction exercises hourly while awake D) Assisting the client to a prone position for 20-30 minutes every 3-4 hours E) Keeping the remaining part of the extremity positioned above the level of the heart F) Encouraging the client to spend as much time as possible in a chair while awake
C, D
A healthcare provider has prescribed carbidopa-levodopa four times per day for a client with Parkinson's disease. The client wants "to end it all now that Parkinson's disease has progressed." What should the nurse do? SATA. A) Explain that the new prescription for carbidopa-levodopa will treat the depression B) Encourage the client to discuss feelings as the carbidopa-levodopa is being administered C) Contact the HCP before administering the carbidopa-levodopa D) Determine if the client is on antidepressants or monoamine oxidase inhibitors (MAOIs) E) Determine if the client is at risk for suicide
C, D, E
After the nurse teaches the client about the use of skeletal traction, which statement made by the client about the purpose of the traction indicates the need for additional teaching? A) "Skeletal traction is used to align injured bones." B) "Skeletal traction provides long-term pull on my bones." C) "25 pounds of traction will be applied to my leg." D) "Skeletal traction is used to pull weight with a boot."
D) "Skeletal traction is used to pull weight with a boot."
The nurse provides care for a client experiencing tonic-clonic seizure activity. The nurse intercedes if which intervention is observed? A) The side rails are raised on the client's bed B) There is suction at the client's bedside C) There is an oxygen set-up at the client's bedside D) A padded tongue blade is placed at the client's bedside
D) A padded tongue blade is placed at the client's bedside
What priority information does the nurse include when teaching a client with Parkinson's Disease about the prescribed drug selegiline, a selective monoamine oxidase type B (MAO-B) inhibitor? A) Take the drug with meals B) Avoid driving or operating heavy machinery C) Take the medication daily at bedtime D) Avoid eating aged cheese or cured meats
D) Avoid eating aged cheese or cured meats
What is the nurse's best action when a client is having a generalized tonic-clonic seizure and becomes cyanotic? A) Raise the head of the bed and apply oxygen by nasal cannula B) Suction the client and alert the Rapid Response Team C) Call the health care provider and obtain intubation equipment D) Stay with the client because the cyanosis is usually self-limiting
D) Stay with the client because the cyanosis is usually self-limiting
Which goal is most realistic for a client diagnosed with Parkinson's disease? A) To cure the disease B) To stop the progression of the disease C) To begin preparations for terminal care D) To maintain optimal body function
D) To maintain optimal body function
Which medication prescription will the nurse clarify before administering it to a client? A) Gabapentin for a client who has partial seizures B) Diazepam rectal gel for a client with status epilepticus C) Carbamazepine for a client with tonic-clonic seizures D) Warfarin for a client who takes phenytoin for seizures
D) Warfarin for a client who takes phenytoin for seizures
A client with a fractured tibia has an external fixation. The health care provider has prescribed a solution of 1/2 normal saline and 1/2 hydrogen peroxide to clean the pin site twice a day. in which order should the nurse cleanse the pin from first to last? All options must be used. A) Inspect the site for redness, swelling, or discharge B) Clean the pin with a cotton swab dipped in the prescribed solution, wiping from the insertion site to the tip of the pin C) Clean the pin insertion site with a cotton swab dipped in the prescribed solution, removing the crust, and wiping away from the site D) Clean the area around the pin insertion site with cotton swabs, dipped in the prescribed solution
D, C, A, B
Which information will the nurse include when teaching client self-care measures after shock wave lithotripsy for kidney stones? SATA. A) Finish the entire prescription of antibiotics to prevent infection B) Pain in the region of the kidneys or bladder is to be expected C) Balance regular exercise with adequate sleep and rest D) Drink at the very least 3 liters of fluids every day E) Your urine may appear bloody for a few days after the procedure F) Watch for and immediately report any bruising to the urologist
A, C, D, E
Which priority teaching points will the nurse include when teaching a client how to prevent low back pain and injury? SATA. A) Use good posture when sitting, standing, and walking B) Participate in a regular exercise program that includes daily aerobic workouts C) Do no wear high-heeled shoes D) Avoid prolonged sitting or standing E) Ensure adequate calcium and Vitamin D intake F) Keep weight within 30% of ideal body weight
A, C, D, E
The health care provider has prescribed phenytoin sodium therapy for a client with seizures. What should the nurse explain to the client about stopping the drug suddenly? A) Physical dependency develops over time B) Status epilepticus may occur C) A hypoglycemic reaction is likely D) Heart block can happen
B) Status epilepticus may occur
A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which nursing action is most important at this time? A) Report hematuria to the HCP B) Strain the urine carefully C) Administer morphine every 3 hours D) Apply warm compresses to the flank areas
B) Strain the urine carefully
The nurse provides care for an older adult client 8 days after an open reduction internal fixation of the right hip. The nurse intervenes if which observation is made? A) The client ate half of the food on the breakfast tray B) The client is not wearing elastic stockings C) The client must have assistance to transfer from the bed to bedside commode D) The client requires pain medication 3 times per day
B) The client is not wearing elastic stockings
The nurse teaches correct body mechanics to the client with lower back pain. Which suggestion by the nurse is most appropriate? A) Bend at the waist when lifting objects." B) "Lift objects with your arms extended." C) "Bend knees when lifting objects." D) "Lean forward when lifting objects."
C) "Bend knees when lifting objects."
A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. He husband asks, "Why does she have this tube inserted in her hip?" Which response would be best? A) "The tube helps us to detect wound infection." B) "This way we will not have to irrigate the wound." C) "Fluid will drain and not accumulate at the site." D) "We have a way to administer antibiotics into the wound."
C) "Fluid will drain and not accumulate at the site."
The nurse teaches assistive personnel how to position a client who had an above-the-knee amputation last week. Which statement by the AP indicates understanding of the teaching? A) "We should keep the surgical leg elevated on two pillows at all times." B) "We should keep the client in a sitting position as long as possible." C) "We should keep the surgical leg as flat on the bed as possible." D) "We should keep the client in a prone position most of the day."
C) "We should keep the surgical leg as flat on the bed as possible."
Which functional assessment is a priority when the nurse assesses a client with Parkinson's disease and notes a mask-like face? A) Ability to sense pain in the facial area B) Ability to hear normal voice tones C) Ability to chew and swallow D) Ability to see in a dim lighted environment
C) Ability to chew and swallow
A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6° F. Which outcome is a priority for this client? A) Prevention of urinary tract complications B) Alleviation of nausea C) Alleviation of pain D) Maintenance fluid and electrolyte balance
C) Alleviation of pain
What is the priority nursing intervention in the postictal phase of a seizure? A) Reorient the client to time, person, and place B) Determine the client's level of sleepiness C) Assess the client's breathing pattern D) Position the client comfortably
C) Assess the client's breathing pattern
Which statement by the client indicates a need for further teaching by the nurse about preventing back injuries? A) "I need to lose weight because I'm too big." B) "I should not stand or sit for a long period of time." C) "It would be best if I could get ergonomic office furniture." D) "Exercise is not going to help my back very much."
D) "Exercise is not going to help my back very much."
A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? A) "The pain will go away after the swelling decreases." B) "That's phantom limb pain, and every amputee has that." C) "Your foot has been amputated, so it's in your head." D) "On a scale of 0-10, how would you rate your pain?"
D) "On a scale of 0-10, how would you rate your pain?"
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
D) Eases the client to the floor
An older adult client has an open reduction and internal fixation of the left femoral head after a fracture. Which action by the nurse is best? A) Offer the client a clear liquid diet B) Keep the client turned to the non-operative side C) Instruct the client to exercise the arms D) Encourage the client to cough and deep breathe every 2 hours
D) Encourage the client to cough and deep breathe every 2 hours
Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? A) Jerking to one extremity that spreads gradually to adjacent areas B) Vacant staring and abruptly ceasing all activity C) Facial grimaces, patting motions, and lip-smacking D) Loss of consciousness, body stiffening, and violent muscles contractions
D) Loss of consciousness, body stiffening, and violent muscles contractions
A client is diagnosed with typical absence seizures. It is most important for the nurse to take which action? A) Place the client on complete 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
D) Monitor the client for brief interruptions of consciousness
Which nursing approach is most helpful to a client with Parkinson's disease who is experiencing a freezing of gait with difficulty initiating movement? A) Pull the client forward to initiate walking B) Instruct the client to use a wheelchair C) Have the client remain still D) Tell the client to march in place
D) Tell the client to march in place
A client with an extracapsular hip fracture is scheduled for internal fixation with the insertion of a pin. What can the nurse tell the client about the reason for this type of treatment for the fracture? A) Hemorrhage at the fracture site is prevented B) Neurovascular impairment risk is decreased C) The risk of infection at the site lessened D) The client is able to be mobilized sooner
D) The client is able to be mobilized sooner
What equipment will the nurse ensure is in the room of a client being admitted to prevent harm? SATA. A) Oxygen equipment B) Padding for side rails C) Suctioning equipment D) Saline lock insertion equipment E) Padded tongue blade F) Neurological assessment flow sheet
A, C, D Rationale: Padded side rails may be embarrassing for the client, padded tongue blades should never be used on a client having a seizure (nothing should be put in their mouth), and while a neurological assessment flow sheet is good to have in the room it does not prevent harm
The nurse is preparing to teach a client who has been prescribed a levodopa-carbidopa preparation for Parkinson's disease. What health teaching will the nurse include for the client and family? SATA. A) "Move slowly when changing positions from sitting to standing." B) "Take your medication after meals to help prevent nausea." C) "Report any hallucinations that the client may have." D) "Note any changes in mental or emotional status." E) "Pay attention to whether your tremors improve or worsen."
A, C, D, E
A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy? A) Mood B) Muscle rigidity C) Appetite D) Alertness
B) Muscle rigidity
Which points and actions will the nurse include when teaching a client and family after a below-the-knee amputation about care of the residual limb? SATA. A) Demonstrating how to apply a figure-eight elastic wrap B) Reviewing the signs and symptoms of wound infection C) Reminding the client and family to rewrap the limb several times each day D) Obtaining a return demonstration of the elastic wrap application E) Reviewing the positioning and exercises for prevention of flexion contractures F) Informing the client that after the incision is healed, it can be cleaned during bathing or showering with soap and water
A, B, C, D, E, F
A client had a percutaneous nephrolithotomy to remove a kidney stone. The client is being discharged with drainage tubes from the kidney. What should the nurse instruct the client to do after the procedure? SATA. A) Avoid heavy lifting for 2-4 weeks B) Return to work after 1 month C) Report fever or chills to the HCP D) Go to the emergency department for bleeding from the drainage tubes E) Strain all urine and report presence of stones
A, C, D
Which is an initial sign of Parkinson's disease? A) Rigidity B) Tremors C) Bradykinesia D) Akinesia
B) Tremors
Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures? A) Maintain the client on bed rest B) Administer a sedative as prescribed C) Close the door to the room to minimize stimulation D) Administer carbamazepine 200 mg PO, twice per day
D) Administer carbamazepine 200 mg PO, twice per day
What nursing assessments should be documented at the beginning of the ictal phase of a seizure? A) Heart rate, respirations, pulse oximeter, and blood pressure B) Last dose of anticonvulsant and circumstances at the time. C) Type of visual, auditory, and olfactory aura the client experienced D) Movement of the head and eyes and muscle rigidity
D) Movement of the head and eyes and muscle rigidity
The nurse is caring for an adult with a grade III compound fracture of the right femur; the client has been placed in skeletal traction. What is the intended outcome of the traction? A) Prevent skin breakdown B) Prevent movement in the bed C) Preserve normal length of the leg D) Reduce and immobilize the fracture
D) Reduce and immobilize the fracture
What is the priority nursing concern when a client is admitted with a history of kidney stones and presents with severe flank pain, nausea and vomiting, pallor, and diaphoresis? A) Possible hemorrhage B) Urinary elimination blockage C) Impaired tissue perfusion D) Severe pain
D) Severe pain
Which does the nurse recognize as cardinal symptoms for a client with Parkinson's disease (PD)? SATA. A) Tremors B) Postural instability C) Bradykinesia or akinesia D) Choreiform movements E) Seizure activity
A, B, C, D
The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order? A) Maintain patent airway B) Record the seizure activity observed C) Ease the client to the floor D) Obtain vital signs
C, A, D, B
Which essential nursing intervention will the nurse implement when a client returns from having shock wave lithotripsy? A) Strain the urine to monitor for the passage of stone fragments B) Report bruising on the affected side immediately to the urologist C) Apply a local anesthetic cream to the client's skin on the affected side D) Continuously monitor for the client's heart pattern for dysrhythmias
A) Strain the urine to monitor for the passage of stone fragments
