Med surg exam 3 ATI practice questions w/ rationales

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome. Which of the following questions should the nurse ask the client?

"Have you had a recent influenza infection?" Rationale: the nurse should ask the client about a recent Haemophilis influenzae infection. The cause of GBS is unknown, but it usually follows a viral infection.

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect?

-muscle distortion -pain behind the ear -impaired taste

A nurse is assessing a client who is meningitis in notes when possibly flexing the clients neck. There is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Brudzinski's sign Rationale: this client is manifesting a positive Brudzinski's sign, which is indicated when the hips and knees flex when the neck is flexed. A positive Brudzinski's sign is a common sign of meningitis.

A nurse in the emergency department is caring for a client who is myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis?

Developing a respiratory infection Rationale: the most common triggers of myasthenic crisis are respiratory infection, not taking, or taking too little, of the prescribed medication, surgery, and high environmental temperatures

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Establish the ability to communicate effectively Rationale: A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?

Evaluate the client's neurological status Rationale: manifestations of a headache and stiff neck (nuchal rigidity) or indication that the client might have meningitis. The greatest risk to the client is injury from increased intracranial pressure, which can lead to brain herniation and death. Therefore, the nurse should complete a neurological assessment as a baseline. If the client does have meningitis, neurological checks should be completed every 2 to 4 hours.

A nurse is presenting discharge instructions to a client who has multiple sclerosis. The client reports symptoms of diplopia, dysmetria and sensory change. Which of the following nursing statements are appropriate?

Implement a schedule to include periods of rest Rationale: Betos, the nurse should assess the client in developing a schedule that includes periods of exercise, followed by period of rest to maintain muscle strength and coordination

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Inability to recognize his family members Rationale: the right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

Incorporate nonverbal cues in the conversation Rationale: nonverbal cues, enhance the client's ability to comprehend and use language

A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take?

Maintain the client on absolute bed rest. Rationale: The nurse should place the client on absolute bed rest in a quiet environment. Activity can elevate blood pressure and increase the risk for bleeding.

A nurse is shopping and find a woman who has collapsed with right-sided weakness and slurred speech which of the following actions should the nurse take?

Notify emergency management services Rationale: the client is exhibiting manifestations of a stroke, and a rapid diagnosis is vital to administering appropriate treatment; therefore, the nurse to call the emergency management services

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mmHg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Place the client in a high-Fowler's position Rationale: The client who is experiencing autonomic dysreflexia is that a risk for a cerebral vascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse's initial action should be to place the client and high-Fowlers position to assist in providing immediate reduction in blood pressure and intracranial pressure.

A nurse is preparing to administer an osmotic diuretics IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

Reduce edema of the brain Rationale: an osmotic diuretic is used to decrease ICP by moving fluid out of the ventricles into the bloodstream

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identifies an indication of increased intracranial pressure?

Restlessness Rationale: increased ICP is a condition in which the pressure of the CSF or brain matter within the skill exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in LOC or a change in speech pattern

Client fell out of bed trying to get to the bathroom, client states "my head hurts". They are anxious and alert. Grimacing when moving their head. GCS goes from a score of 15 to 14 in 1 hour. Client is experiencing tonic clinic seizures for approximately 1 minute. Client is not oriented to time. Client states "I'm scared I'm going to die! My head really hurts". Client is agitated and restless. HR is irregular and client is bradycardic. Client is experiencing weakness on the right side of the body, the right eye pupil is dilated and their left eye pupil is reactive to light. GCS went down to 13 and they are confused and unable to follow commands.

The client is at highest risk for developing intracranial hemorrhage as evidenced by the client's GCS following the client's fall. Intracranial hemorrhage is a hematoma or clot in the brain often caused by injury. The nurse should monitor the client's neurological status and vital signs, along with seizure activity which can increase ICP and be life threatening.

A nurse is receiving a transfer report for a client who had a head injury. The client has a Glasgow coma scale score of 3 for eye-opening, 5 for best verbal response and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens their eyes when spoken to Rationale: A GCS of 3-5-5 indicated that the client opens their eyes in response to speech, is oriented, and is able to localize pain

A nurse is teaching the family have a client who is receiving treatment for spinal cord injury with a halo fixation device. which of the following statements should the nurse make?

The purpose of this device is to immobilize the cervical spine Rationale: a client who has an injury to the cervical spine can have a halo fixation device to provide immobilization of the head and neck for a period of 8 to 12 weeks

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report?

having a decreased ability to perceive colors Rationale: symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive colors

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the clients provider?

"I need something for the pain in my eye. I can't stand it" Rationale: following cataract surgery, the client should expect only mild pain and should immediately report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery might indicate increased intraocular pressure or hemorrhage.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?

A self-report pain rating scale Rationale: expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what is sad, but is unable to communicate verbally. However, this does not necessarily mean that a client is unable to reliably report pain. evidence based practice indicates the nurse should first attempt to obtain the client self report of pain. When assessing a client for pain, the nurse should utilize the hierarchy of pain measures which begins with self report. It is always better to use a subjective method, such as a client report, instead of an objective method, such as something that is observable by the nurse, which is much less reliable.

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the clients plan of care?

Ability to self-feed with the use of adaptive equipment Rationale: a client who has had a spinal cord transection at the level of the fifth cervical vertebrae should have full neck, partial shoulder, back, biceps, and gross elbow movement. A realistic rehabilitation goal for the client is the ability to feed themself with the use of adaptive equipment.

A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mmHg. Which of the following actions should the nurse take?

Adjust the client's head of bed Rationale: the nurse should adjust the client's HOB to keep CPP greater than 70 mmHg

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Decreased level of consciousness Rationale: as intracranial pressure increases cerebral perfusion, and therefore level of consciousness decrease. Other manifestations include severe headache, irritability, and peoples that are slow to react or are unreactive to light.

A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcome should the nurse expect to see?

Decreased tremors Rationale: Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty walking and problems with balance and coordination. Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may be helpful in controlling tremors in the early stage of the disease.

A nurse is teaching a client who is taking benztropine to treat Parkinson's disease. The nurse instruct the client to report which of the following adverse effects?

Difficulty voiding Rationale: The nurse should instruct the client to report difficulty voiding, which may indicate urinary retention, as an adverse effect of benztropine. Benztropine is an anticholinergic medication that helps decrease the rigidity and tremors of Parkinson's disease.

A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instruction should the nurse include?

Keep your head up and straight Rationale: keeping the head straight and avoiding looking down prevents increasing intraocular pressure

A nurse is assessing a client who was involved in a motor vehicle crash. Which of the following techniques to the nurse use to test corneal reflexes?

Lightly touch the eyes with a wisp of cotton Rationale: the nurse should lightly touch a cornea with a wisp of cotton. Absent corneal reflexes, or the loss of the ability to blink, can be caused by hand injury or stroke

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client ..

Makes up stories when he is unable to remember actual events Rationale: Confabulating is filling in gaps in memory by fabrication. A client who has dementia may do this unconsciously to cover for and decrease anxiety about memory gaps.

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Manifestations preceded by a severe headache Rationale: a hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

Minimize environmental stimuli Rationale: a client who has a cerebral aneurysm is at risk for rupture, and should avoid any stimulation that could cause anxiety such as noise or bright lights

A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following action should the nurse take?

Monitor sensory perception of the lower extremities Rationale: the nurse should perform neurologic assessments, focusing on sensory perception of the lower extremities every four hours. Any decrease in sensation by the client requires immediate notification of the provider.

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebra. When planning care, the nurse anticipate which of the following types of disability?

Paraplegia Rationale: Paraplegia or paralysis of both legs, is seen after a SCI below T1

A nurse is assessing a client who reports ear pain for the past three days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?

Perforated tympanic membrane Rationale: the client has manifestations of otitis media with a perforated tympanic membrane (eardrum). Ear pain is reduced when fluid and pus drained from the eardrum due to the perforation.

A nurse is assessing a client who has ataxia. Which of the following action should the nurse take to evaluate the clients ability to safely ambulate?

Perform a romberg's test Rationale: the nurse should perform a Romberg test to check the clients ability to maintain an upright position without swaying, when standing with feet close together, with eyes open and with eyes closed. The nurse must stand close enough to prevent a client from falling.

A nurse is developing a plan of care for a client who is postoperative following a pneumatic retinopexy to repair a detached retina. which of the following intervention should the nurse include in the plan?

Position the client prone Rationale: the client is positioned on the abdomen if oil or gas is placed in the eye during the surgery. This position allows the injected bubble to float into position overlying the area of detachment and provide consistent pressure to reattach the retina.

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?

Prepare the client for mechanical ventilation Rationale: the client who is experiencing a myasthenic crisis is at risk for loss of adequate respiratory function. The nurse should closely monitor the client's respiratory status and prepare for possible mechanical ventilation.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Provide client supervision Rationale: because the clients voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment

A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse instruct the client to monitor for which of the following complications?

Pulmonary embolism Rationale: altered atrial contractions, can cause blood pooling, and thrombus formation. The client is at risk for developing a pulmonary embolism or embolic stroke. The client should monitor and report immediately manifestations, such a shortness of breath or neurological changes.

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

Severe headache Rationale: the nurse should expect a client who has meningitis to manifest a severe headache due to meningeal inflammation.

A nurse is reinforcing discharge instructions with a client following a laminectomy. Which of the following instruction should the nurse include?

Sit in straight-back chairs Rationale: the client should sit in straight back chairs to provide support to the spine and minimize strain on the surgical site

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

Small drops of clear fluid in left ear Rationale: clear fluid in the ear canal might be CSF and indicates a basilar skull fracture. CSF drainage is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents. This finding should be reported to the provider.

A nurse is caring for a client who has global aphasia. Which of the following action should the nurse take?

Speak to the client about one idea at a time Rationale: the nurse should speak using sentences that contain one clear thought or idea for better communication and understanding

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

Suction saliva from the clients mouth Rationale: the unconscious client is unable to independently maintain a clear airway and is at risk for ineffective airway clearance according to the safety and risk reduction priority setting framework, maintaining the clients airway, breathing, and circulation is the highest priority

A nurse is teaching the family of a client who is Alzheimer's disease about donepezil. Which of the following information should the nurse include in the teaching?

Syncope episodes may occur when taking this medication rationale: the nurse should inform the family to monitor for syncope, which places the client at risk for falling

A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse closely monitor the client for increased intracranial pressure as indicated by which of the following findings?

Widened pulse pressure Rationale: a widened pulse pressure is a manifestation of increased ICP. Other manifestations include bradycardia, vomiting and decreased LOC

A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses to the nurse make?

"Please ring for assurance when you wish to get out of bed" Rationale: this response is appropriate. With assistance, the client can ambulate safely. Tinnitus, one side hearing loss, and vertigo are all manifestations of Ménière's disease that can increase the clients risk of falls when ambulating.

A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. Which of the following statements should the nurse include in the teaching?

"You may experience drowsiness while taking this medication." Rationale: the nurse instruct the client that drowsiness can occur while taking this medication, and to exercise caution while performing activities that require alertness

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse that the client is experiencing an increase in intracranial pressure?

-headache -slurred speech -pupillary changes -disorientation

A nurse is caring for a client who has a mild traumatic brain injury. Which of the following manifestations should the nurse immediately report to the provider?

A change in the GCS score from 13 to 11. Rationale: In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider.

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

A lucid period followed by an immediate loss of consciousness Rationale: the nurse should expect the client who has an epidural hematoma to have a lucid period, followed by an immediate loss of consciousness, which is caused by arterial bleeding into the space between the dura and skull.

A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following intervention should the nurse take?

Allow the drainage to drop onto a sterile gauze pad Rationale: the nurse should allow the drainage to drip onto a sterile gauze pad in order to assess for the presence of cerebrospinal fluid. This intervention allows for the collection of data, without increasing the risk for further injury.

A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor vehicle crash. Which of the following is an expected finding for this client?

Alternating periods of alertness and unconsciousness Rationale: alternating periods of alertness and unconsciousness is a common manifestation of an epidural hematoma

A nurse is assessing a client who has a spinal cord injury. Which of the following action should the nurse take to monitor C4 function?

Apply downward pressure while the client shrugs their shoulders upward Rationale: this assessment monitors the motor function of C4 to C5

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instruction should the nurse include?

Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week Rationale: the nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 10 lbs for 1 week following surgery.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia Rationale: the nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following action should the nurse take?

Call emergency services Rationale: the client may have had a stroke, and if she has, she needs emergency medical intervention and transport to a stroke center

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?

Cheddar cheese Rationale: the nurse should eliminate aged cheeses from the diet of a client who is prescribed selegiline. Cheddar cheese contains tyramine, which can cause a hypertensive crisis.

A nurse is caring for a client who has increased intracranial pressure. Which of the following intervention should the nurse take?

Elevate the HOB Rationale: the nurse should elevate the head of the bed 30° to 45° to promote reduction of intracranial pressure wall monitoring for changes in blood pressure

A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following intervention should the nurse take?

Elevate the HOB to 30° Rationale: the client who has surgery to treat a supratentorial brain tumor is at risk for increased ICP. Elevation of the HOB to 30° assists in promoting venous and CNS fluid drainage from the head to prevent increased ICP.

A nurse is implementing precautions for a client who has a cerebral aneurysm. Which of the following nursing intervention should the nurse implement?

Encourage exhaling through mouth during defacation Rationale: the nurse should encourage the client to exhale through the mouth when defacating to decrease strain

A nurse is instructing a clients family members about feeding safety for a client who has dysphasia following a stroke. which of the following instruction should the nurse include?

Encourage the client to take small bites Rationale: the family members should encourage the client to take small bites and chew food thoroughly in order to prevent choking

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Instruct the client to look up and down without moving his head Rationale: the nurse should observe the client's extraocular eye movements by instructing him to look at the cardinal fields of gaze as part of an evaluation of the function of cranial nerve III (oculomotor)

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse?

Intracranial pressure (ICP) of 18 mmHg Rationale: the client's ICP level is above the expected reference range of 10-15 mmHg. ICP increases with suctioning, coughing, sneezing, straining and frequent positioning

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Irritability Rationale: the nurse should monitor the client for behavioral changes such as confusion, restlessness and irritability as manifestations of increased intracranial pressure.

A nurse is planning care for a client who has a halo fixation device. Which of the following action should the nurse include in the plan of care?

Monitor the client for an elevated temperature Rationale: a halo fixation device is used to stabilize a cervical fracture on a client. The device is secured with four screws inserted directly into the client skull to promote cervical alignment. Complications include loose pins, local infection, and scarring. More serious complications include osteomyelitis, subdural, abscess, and instability. The nurse should monitor and report manifestations of infection, such as fever and purulent drainage from pin sites.

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

Muscle contractions become progressively stronger Rationale: a positive tensilon test is indicated by a 4-5 minute period of improved muscle tone and strength

A nurse is caring for a client who has an intracranial pressure (ICP) set lights reading of 40 mmHg. Which of the following findings should the nurse identify as a late sign of ICP?

Nonreactive pupils and bradycardia

A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse's priority?

Notify the surgeon Rationale: purulent drainage is a manifestation of infection and should be reported to the surgeon immediately

Client has manifestations of meningitis including headache, elevated temperature, lethargy, vomiting, rash and photosensitivity

Nurse should implement seizure precautions and dim the lights in the client's room because the client has manifestation of meningitis. Nurse should assess the client's neurologic status and the client's temperature every 2-4 hours to monitor for changes that can indicate an increase in the client's ICP and worsening infection.

A nurse is caring for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

Place suction equipment at the client's bedside Rationale: cranial nerves IX (glossopharyngeal) and X (vague) innervate the muscles of the soft palate, larynx, and pharynx. Impairment of these nerves places the client at risk for aspiration, making it necessary for the nurse to have access to suction for the client.

A nurse is caring for a client who has a spinal cord injury and suspects. The client is developing autonomic dysreflexia. Which of the following action should the nurse take first?

Place the client in a sitting position Rationale: the nurse should use the least invasive intervention first. therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertension

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurses told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Plantar flexion of the legs Rationale: plantar flexion of the legs is an indicator of the decorticate posturing, and is a result of lesions of the corticospinal tracts

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

Pushes the painful stimulus away Rationale: Pushing away a painful stimulus is an expected response.

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. which of the following intervention should the nurse include in the plan?

Reduce stimuli Rationale: the nurse should reduce stimuli by decreasing the number of visitors, speaking calmly, and creating a quiet environment

A nurse caring for a client who had a right sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following action should the nurse take?

Remind the client to look for food on the left side of the tray Rationale: the nurse's action to remind the client to look for food on the left side of the tray will train the client to scan the tray by moving his head and eyes, which will help to resolve the problem of homonymous hemianopsia.

A nurse is caring for a client four hours following evacuation of a subdural hematoma. Which of the following assessment is the nurses priority?

Respiratory status Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respirations, noting the rate and pattern and evaluating arterial blood gases. Following intercranial surgery, even slight hypoxia can worsen cerebral ischemia.

A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following pre-operative instructions should the nurse include?

Restrict head movement Rationale: The client should restrict head and eye movement to prevent further detachment prior to surgery

A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instruction should the nurse include?

Restrict lifting objects greater than 10 pounds Rationale: the nurse instruct the client to restrict lifting objects greater than 10 pounds to reduce the rest for increased interocular pressure

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?

Sensitivity to light Rationale: the nurse should expect a client who has a mild traumatic brain injury, such as a concussion, to have sensitivity to light and noise

A nurse is caring for a 24 year old client who reports a recent fall, hitting their head and right shoulder after slipping on a wet floor yesterday. Denies LOC. Complains of pain in right shoulder. Has taken both acetaminophen and ibuprofen for pain with minimal relief obtained. Stayed up entire night playing video games yesterday to distract self from pain. Reports intermittent nausea and vomiting. Nurse's notes (0900): reports pain in right shoulder. Limited ROM notes. Rates pain 7/10. Denies numbness and tingling in arm. No swelling or bruising over the shoulder. Fingers warm with Cap refill less than 3 seconds, sensation intact. Drowsy. Oriented to person, place, and time. Irritable and restless at times. PERRLA. GCS of 15. No hematomas noted on head. No N/V this time. 1000: continues to report pain in right shoulder. Pain increased from 7 to an 8/10. Increased drowsiness noted. GCS unchanged. Vital signs: - Oral temp: 37.5 (99.6) - HR: 76/min and regular - RR: 20/min, even and unlabored - BP: 112/70 mmHg in left arm - Pulse oximetry: 98% RA

The nurse should first address the client's drowsiness followed by the client's right shoulder pain. Rationale: the nurse and address the clients right shoulder pain after addressing the clients drowsiness. a clients recovery can be affected by pain by inhibiting their ability to become active and involved in self-care. The goal is to provide pain relief so that the client is able to participate in the recovery and to improve the clients functional status. Assessment of paint should include intensity, quality, duration, and location.

Patient admitted with a possible diagnosis of infective endocarditis and prescribed gentamicin. Client is exhibiting signs of headache, dizziness, nausea and tinnitus. Client's diagnostic lab wailers also indicated an increase in BUN, creatinine, gentamicin peak level, AST/ALT.

The nurse should identify that the priority hypothesis is that the greatest risk for the client is developing hearing loss due to antibiotics. Ototoxicity may occur in clients who are receiving aminoglycosides, such as gentamicin. An increase in BUN, creatinine, gentamicin peak level, ALT/AST all place the client at risk for ototoxicity and hearing loss. Hearing loss is generally in the high frequency range and is associated with peak aminoglycoside levels that continue to remain elevated.

A nurse is caring for a client who has increased intracranial pressure following a closed head injury. Which of the following action should the nurse take?

Use log rolling to reposition the client Rationale: treatment of increased intracranial pressure focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when positioned.

Client reports a headache described as "the worst headache of their life", ringing in the ears, photophobia and left-sided weakness. Client also has crying aphasia, and left sided upper and lower extremity weakness. Patient is currently taking lisinopril and warfarin. Patient is hypertensive and has an increased INR

This patient is potentially having a hemorrhagic stroke. 2 actions the nurse should take is to prepare the client for a STAT CT of the brain and place the client on seizure precautions. Parameters to monitor include BP and PT/INR levels.

A nurse is providing post operative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include?

Vision will be greatly improved on the day or surgery Rationale: vision should be greatly improved on the day of surgery. This info should be included in the teaching.

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching?

Without treatment, glaucoma can cause blindness Rationale: the nurse should explain that without treatment glaucoma can result in blindness due to irreversible damage to the retina and optic nerve

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure. Which of the following assessment findings by the nurse supports this suspicion?

restlessness Rationale: clients who have meningitis can be at risk for developing increased intracranial pressure. The nurse should monitor the client's vital signs and neurological status at least every 4 hours. Indications of increased intracranial pressure include increased restlessness and confusion, a decreased level of consciousness and the presence of Cushing's triad (severe hypertension, widened pulse pressure and bradycardia)

A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching?

the client should wear dark glasses while outdoors Rationale: the nurse instruct the client and his spouse that he should wear dark glasses, went outside or in bright light until pupil reaction returns

Assessment findings and their relationship with Parkinson's disease, stroke and multiple sclerosis.

• Parkinson's disease: cognitive function, speech , mobility status, ambulation pattern, muscle movements, facial rigidity, orientation status • Stroke: facial symmetry, blood pressure, cognitive function, speech, mobility status, orientation status • Multiple sclerosis: cognitive function, speech, mobility status, orientation status

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications?

• hypotension- lack of sympathetic input can cause a decrease in blood pressure. The nurse should maintain the client's SBP at 90 mmHg or above to adequately perfuse the spinal cord. •absence of bowel sounds- spinal shock leads to decreased peristalsis, which could cause the client to develop a paralytic ileus • weakened gag reflex- the nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake