Musculoskeletal/Neurological Quiz- EAQ

A client who sustained a cerebrovascular accident becomes incontinent of feces. Which nursing intervention is most important for supporting the success of the client's bowel training program? A. Use prescribed medications to induce elimination B. Adhere to a definite time for attempted evacuations. C. Consider previous habits associated with the client's defecation. D. Time scheduled eliminations to take advantage of the gastrocolic reflex.

ANS: B Adhere to a definite time for attempted evacuations.

A client is undergoing diagnostic testing for myasthenia gravis. Which test would the nurse identify as the most specific for this diagnosis? A. Electromyography B. Pyridostigmine test C. Edrophonium chloride test D. History of physical deterioration

ANS: C Edrophonium chloride test

A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which areas of paralysis would the nurse expect to find upon assessment? Select all that apply. A. Left leg B. Left arm C. Right leg D. Right arm E. Left side of face

ANS: A, B, E

Identify the type of hypersensitivity reaction associated with systemic lupus erythematosus (SLE). A. Type I B. Type II C. Type III D. Type IV

ANS: C Type III Rationale: SLE is an example of an immune complex-mediate, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I, or immediate hypersensitive reaction. Cytotoxic, or type II, hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions caused by delayed, or type IV, hypersensitivity reactions.

An older adult client is admitted to the health care facility following a stroke. Which action is correct when the client's cousin asks to see the client's health record? A. Confirm the client's relationship first B. Ask the client's primary health care provider C. Inform the nurse manager and show the records D. Explain that medical health records are confidential.

ANS: D Explain that medical health records are confidential.

A client begins treatment with pyridostigmine bromide therapy for myasthenia gravis. Which action would the nurse perform in administration of the medication? A. Administer the medication after meals. B. Administer the medication on an empty stomach C. Evaluate the client's psychological responses between medication doses. D. Evaluate the client's muscle strength every hour after the medication is given.

ANS: D Evaluate the client's muscle strength every hour after the medication is given. Rationale: The onset of action of pyridostigmine is 30 to 45 minutes after administration, and the effects last up to 6 hours; the client's response will influence dosage levels. Pyridostigmine usually is administered before meals to promote mastication. Pyridostigmine should be administered with food to prevent gastric irritation. There are no psychological side effects associated with pyridostigmine.

A client newly with myasthenia gravis voiced concerns about fluctuations in physical condition and generalized weakness. When providing care for this client, which nursing intervention would the nurse implement? A. Preplan the spacing of activities throughout the day. B. Restrict activities and encourage bed rest. C. Teach the client about limitations imposed by the disorder. D. Have a family member stay at the bedside to give the client support.

ANS: A Preplan the spacing of activities throughout the day.

A client who recently gave birth has myasthenia gravis. For which clinical manifestation would the nurse monitor the newborn? A. Seizures B. Restlessness C. Hypoglycemia D. Feeble limb movements

ANS: D Feeble limb movements

Which amount of time is the maximum amount the nurse would permit an older adult with a cerebrovascular accident to remain in one position? A. 1 to 2 hours B. 3 to 4 hours C. 15 to 20 minutes D. 30 to 40 minutes

ANS: A 1 to 2 hours

A client is experiencing an exacerbation of systemic lupus erythematosus. To reduce the frequency of exacerbations, what would be important for the nurse to include in the client's teaching plan? A. Basic principles of hygiene B. Techniques to reduce stress C. Measures to improve nutrition D. Signs of an impending exacerbation

ANS: B Techniques to reduce stress Rationale: Systemic lupus erythematosus is an autoimmune disorder, and physical and emotional stresses have been identified as contributing factors to the occurrence of exacerbations. Although basic principles of hygiene should be performed, inadequate hygience is not known to produce exacerbations. Although measures to improve nutrition should be done, nutritional status is not significantly correlated to exacerbations. Knowledge of the symptoms will not decrease the occurrence of exacerbations.

Which educational topic is a high priority for the nurse providing education to a client with systemic lupus erythematosus? A. Instructing about ways to protect the skin B. Helping the client identify coping strategies C. Teaching methods to monitor body temperature D. Teaching about the effects of the disease on lifestyle

ANS: A Instructing about ways to protect the skin Rationale: A client with systemic lupus erythematosus is first taught to protect the skin to prevent infections. Helping the client with identifying coping strategies is given low priority. Different methods are taught to monitor body temperature because fever is a major sign of exacerbation. Teaching about the effects of the disease on lifestyle occurs after teaching ways to protect the skin.

Which assessment finding indicates that a client has had a stroke? Select all that apply. A. Lopsided smile B. Unilateral vision C. Incoherent speech D. Unable to raise right arm E. Symptoms started 2 hours ago

ANS: A, B, C, D, E

Which clinical manifestations may indicate a client has systemic lupus erythematosus (SLE)? Select all that apply. A. Pericarditis B. Esophagitis C. Fibrotic skin D. Discoid lesions E. Pleural effusions

ANS: A, D, E

Which test is used in the diagnosis of systemic lupus erythematosus? A. Patch test B. Photo patch test C. Direct immunofluorescence test D. Indirect immunofluorescence test

ANS: C Direct immunofluorescence test Rationale: A direct immunofluorescence test is used in the diagnosis of systemic lupus erythematosus. The patch test and photo patch test are used to evaluate allergic dermatitis and photo allergic reactions. An indirect immunofluorescence test is performed on a blood sample.

Which type of hypersensitivity reaction occurs in the client with systemic lupus erythematosus (SLE)? A. Type I B. Type II C. Type III D. Type IV

ANS: C Type III

While caring for a client with heat stroke, the nurse measured the temperature and noted it as 109 F. Convert this temperature into Celsius and record your number using one decimal place. __________C

ANS: 42.8 C C= (F-32) (5/9) C= (109-32) (5/9) C= 42.8

The nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? A. Neurological B. Wound C. Pain D. Skin

ANS: C Pain

The nurse assesses a client with severe nodule-forming rheumatoid arthritis for possible Felty syndrome. Which assessment findings are consistent with Felty syndrome? Select all that apply. A. Itchy eyes B. Dry mouth C. Leukopenia D. Splenomegaly E. Photosensitivity

ANS: C, D C. Leukopenia D. Splenomegaly Rationale: Felty syndrome occurs most commonly in clients with severe nodule-forming rheumatoid arthritis; and characterized by splenomegaly and leukopenia. Itchy eyes, dry mouth, and photosensitivity are all signs of Sjogren syndrome.

The nurse is counseling a client with amyotrophic lateral sclerosis (ALS) about management of this disorder. What important suggestion should the nurse make to the client? A. "Eye surgery may improve your vision." B. "Activities should be spaced throughout the day." C. "Opioids may be necessary for the pains in your legs." D. "Leg restraints will decrease the chance of physical injury.

ANS: B "Activities should be spaced throughout the day."

Which type of hypersensitivity reaction would the nurse teach a client with rheumatoid arthritis (RA)? A. Delayed B. Cytotoxic C. Immunoglobulin E (IgE)-mediated D. Immune complex

ANS: D Immune complex Rationale: RA is an autoimmune disorder associate with immune-complex type of hypersensitivity reaction. Contact dermatitis caused by poison ivy is associated with a delated type of hypersensitivity reaction. Goodpasture syndrome is associated with a cytotoxic type of hypersensitivity reaction. Asthma is associated with an IgE-mediated type of hypersensitivity reaction.

Pyridostigmine is prescribed for a client with myasthenia gravis. Why would the nurse instruct the client to take pyridostigmine about 1 hour before meals? A. This timing limits first pass metabolism B. Taking it on an empty stomach increases absorption. C. Taking it before meals decreases gastric irritation. D. Taking it before meals improves the ability to chew.

ANS: D Taking it before meals improves the ability to chew.

A client has a heart rate of 72 beats/min and stroke volume of 70 mL. What is the client's cardiac output? Record your answer using a whole number. _________ mL/min

ANS: 5040 mL/min The volume of blood pumped by the heart in 1 minute is the cardiac output. Cardiac output is the product of the heart rate and the stroke volume of the ventricle. Cardiac output in the client with a heart rate of 72 beats/min and stroke volume of 70 mL is 5040 mL/min: 72 X 70 = 5040.

The nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). Which recommendations are essential for the nurse to include? Select all that apply. A. "Wear a large-brimmed hat." B. "Take your temperature daily." C. "Balance periods of rest and activity." D. "Use a strong soap when washing the skin." E. "Expose the skin to the sun as often as possible."

ANS: A, B, C Rationale: A fever is the major sign of an exacerbation. A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. SLE can cause alopecia, and hair care recommendations include the use of mild protein shampoos and avoidance of harsh treatments, like permanents or highlights, and use of large-brimmed hat for skin protection. Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion should be applied. Exposing the skin to the sun as often as possible is not recommended. Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.

Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring? Select all that apply. A. Wearing a medical alert bracelet B. Initiating bleeding precautions C. Refraining from estrogen therapy D. Obtaining routine prothrombin times E. Notifying providers of anticoagulation

ANS: A, B, C, D, E

The nurse is preparing to discharge a client who is partially paralyzed after a stroke. Which behaviors would the nurse alert the family of as symptoms of caregiver role strain? Select all that apply. A. Disturbed sleep patterns B. Reduced appetite and weight C. Concerned about personal appearance D. Engages in leisure activities as often as possible E. Fearful about administering medications to the client

ANS: A, B, E Rationale: A family should recognize that when the caregiver has disturbed sleep patterns, the caregiver is experiencing strain. Changes in appetite, weight, and sleep patterns are all indicative of caregiver role strain. A caregiver experiences strain while learning about new therapies and administering medications to the client. A caregiver experiencing role strain is not concerned about personal appearance and may withdraw from social groups. A caregiver also does not spend time in any leisure activities if overcome by strain.

When developing the plan of care for a client with rheumatoid arthritis, which client consideration would the nurse include? A. Surgery B. Comfort C. Education D. Motivation

ANS: B Comfort Rationale: Because pain is an all-encompassing and often demoralizing experience, the nurse would want to keep the client as pain-free as possible. Surgery corrects deformities and facilitates movement, which is not an immediate need. Concentration and motivation are difficult when a client is in severe pain.

Which assessment findings would the nurse identify in a client with clinical manifestations of rheumatoid arthritis (RA)? Select all that apply. A. Obesity and asymmetric joint disease B. Development of antinuclear antibodies C. Inflammatory disease pattern D. Bilateral involvement of metacarpophalangeal joints E. Disease process involving the distal interphalangeal joints F. Disease in the weight-bearing joints and hands

ANS: B, C, D Rationale: RA is an autoimmune disorder identified by the presence of antinuclear antibodies. RA generally affects the joints of the wrist; metacarpophalangeal joints; proximal interphalangeal; elbow; glenohumeral joints; cervical spine; and hip, knee, ankle, tarsal, and metatarsophalangeal joints bilaterally. RA involves inflammation of the joints bilaterally. Osteoarthritis involves degeneration of the joints. Obesity is a risk factor for osteoarthritis. Osteoarthritis asymmetrically affects weight-bearing joints and the hands.

Which information would the nurse consider when planning care for a group of clients with myasthenia gravis, Guillain-Barre syndrome, and amyotrophic lateral sclerosis (ALS)? A. Progressive deterioration until death B. Deficiencies of essential neurotransmitters C. Increased risk for respiratory complications D. Involuntary twitching of small muscle groups

ANS: C Increased risk for respiratory complications Rationale: All 3 share increased risk for respiratory complications. As a result of muscle weakness, the vital capacity is reduced, leading to increased risk of respiratory complications; impaired swallowing can also lead to aspiration. Although ALS is progressive, clients with myasthenia gravis may be stable with treatment, and clients with Guillain-Barre syndrome may experience a complete recovery. None of these diseases are caused by a lack of neurotransmitters; only myasthenia gravis is associated with a decreased number of receptor sites. Twitching is not expected with myasthenia gravis or Guillain-Barre syndrome.

A client admitted to the hospital with the diagnosis of a right-sided "brain attack" (stroke) is right-handed. Which task will be most difficult for this client? A. Eating meals B. Writing letters C. Combing the hair D. Dressing every morning

ANS: D Dressing every morning

For optimum nutrition, which intervention would the nurse implement when determining a client, who sustained a cerebrovascular accident, needs assistance with eating? A. Request that the client's food be pureed. B. Feed the client to conserve the client's energy. C. Have a family member assist the client with each meal. D. Encourage the client to participate in the feeding process.

ANS: D Encourage the client to participate in the feeding process. Rationale: As part of the rehabilitative process after a brain attack, clients should be encouraged to participate in their own care to the extent that they are able and extend their abilities by establishing short-term goals. A client with a brain attack may or may not have dysphagia; altering the consistency of food without the need to do so may make it less palatable. Making the client feel helpless discourages independence. Having a family member assist the client with each meal is unrealistic; family members may not be available because of other responsibilities.

After a cerebrovascular accident (CVA, also known as "brain attack"), a client is unable to differentiate between hot or cold and sharp or dull sensory stimulation. The nurse would conclude the CVA affected which lobe of the brain? A. Frontal B. Parietal C. Occipital D. Temporal

ANS: B Parietal Rationale: Sensory impulses from temperature, touch, and pain travel via the spinothalamic pathway to the thalamus and then to the postcentral gyrus of the parietal lobe, the somatosensory area. The frontal area is the area of abstract thinking and muscular movements. The occipital area of the brain is where nerve impulses translate into sight. The temporal area is the area where nerve impulses translate into sound.

A client taking ibuprofen for rheumatoid arthritis asks the nurse if acetaminophen can be substituted. Which response by the nurse is appropriate? A. "Yes, both are antipyretics and have the same effect." B. "Acetaminophen irritates the stomach more than ibuprofen does." C. "Acetaminophen is the preferred treatment for rheumatoid arthritis." D. "Ibuprofen has anti-inflammatory properties, and acetaminophen does not."

ANS: D "Ibuprofen has anti-inflammatory properties, and acetaminophen does not." Rationale: Ibuprofen has an anti-inflammatory action that relieves the inflammation and pain associated with arthritis. Ibuprofen is not an antipyretic. Acetaminophen does not cause gastritis; this is an effect of aspirin. Acetaminophen is not a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs are preferred for the treatment of rheumatoid arthritis.

A client with systemic lupus erythematosus (SLE) is at 39 weeks' gestation. Which would the nurse anticipate regarding this client? A. A newborn large for gestational age B. The possible need for postpartum dialysis C. Greater prominence of the butterfly-shaped rash D. A need to discontinue the client's salicylate therapy

ANS: D A need to discontinue the client's salicylate therapy Rationale: Salicylate therapy is used because clients with SLE have an increased risk of thrombus formation; as the time of birth approaches salicylate therapy should be discontinued to reduce the possibility of bleeding in the newborn. There is a greater probability that the newborn will be small for gestational age. There is no need for dialysis during the postpartum period. The butterfly-shaped rash that may occur with SLE does not become more prominent during late pregnancy.

A 50-year-old client has difficulty communicating because of expressive aphasia after a cerebrovascular accident. When the nurse inquired about the client's feelings, the spouse responded. Which communication strategy would the nurse use to address this behavior? A. Ask the spouse to know the client's feelings B. Instruct the spouse to let the client answer C. When the spouse leaves, return to speak with the client D. Acknowledge the spouse, but look at the client for a response.

ANS: D Acknowledge the spouse, but look at the client for a response.

Which is the priority nursing intervention for a client admitted to the hospital with a brain attack (cerebrovascular accident)? A. Changing position every 2 hours B. Keeping a serial record of the pulse C. Performing range-of-motion exercises D. Monitoring for increased intracranial pressure.

ANS: D Monitoring for increased intracranial pressure

The nurse was assessing an older adult client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. Which would be the approximate stroke volume? A. 70 mL B. 60 mL C. 50 mL D. 40 mL

ANS:A 70 mL Rationale: Cardiac output is obtained by multiplying the heart rate and the stroke volume. To obtain the stroke volume, the cardiac output should be divided by pulse rate. Dividing 5950 by 85 yields a stroke volume of 70 mL.

A client with systemic lupus erythematosus is taking prednisone. Which foods would the nurse encourage the client to eat while receiving treatment to prevent hypolakemia? A. Broccoli B. Oatmeal C. Fried rice D. Cooked carrots

ANS: A Broccoli Rationale: Potassium is plentiful in green leafy vegetables; broccoli provides 207 mg of potassium per half cup. Oatmeal provides 73 mg of potassium per half cup. Rice provides 29 mg of potassium per half cup. Cooked fresh carrots provide 172 mg of potassium per half cup; canned carrots provide only 93 mg of potassium per half cup.

The nurse assisted a client with myasthenia gravis to bathe. The nurse identified the client's arms had progressively become weaker with sustained movement. Which intervention would the nurse implement with this client? A. Encourage the client to rest for short periods B. Continue the bath while supporting the client's arms C. Gradually increase the client's activity level each day D. Administer a dose of pyridostigmine bromide.

ANS: A Encourage the client to rest for short periods Rationale: Rest will decrease the demands at the synaptic membrane of the neuromuscular junction, reducing fatigue; pace client activity to prevent fatigue before it begins. Continuing the bath while supporting the client's arms and gradually increasing the client's activity level each day will aggravate the fatigue; activity and rest should be delicately balanced to prevent fatigue. Administering a dose of pyridostigmine bromide cannot be done without a health care provider's prescription; rest will usually alleviate the client's fatigue.

Family members of a client who had a brain attack (cerebrovascular accident, CVA) ask why the client cries easily and without provocation. Which explanation would the nurse provide about the client's behavior? A. Has little control over this behavior B. Is making an attempt to get attention C. Feels guilty about the demands being made on the family D. Has selective memory from the past, especially the sad events

ANS: A Has little control over this behavior Rationale: Emotional instability usually is caused by lesions affecting the thalamic area (the part of the neural system most responsible for emotions). Crying easily is not attention-getting behavior; lability of mood is a physiological response to the CVA. The client may have remote memory, but there is no selective process of what events are remembered. There are inadequate date to come to the conclusion that the client feels guilt. Lability of mood is a physiological response to the CVA.

A client reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as a heat stroke? A. Increased heart rate B. Increased blood pressure C. Decreased respiratory rate D. Increased circulatory damage

ANS: A Increased heart rate Rationale: Prolonged exposure to the sun or a high environmental temperature overwhelms the body's heat-loss mechanisms. These conditions cause heat stroke, which manifests as giddiness, excessive thirst, and nausea. An increased heart rate (HR) characterizes a heat stroke. A low blood pressure (BP), increased respiratory rate, and increased circulatory and tissue damage are not indicators of heat stroke.

A client with rheumatoid arthritis is in the convalescent stage of an exacerbation. The client states, "The only time I am without pain is when I lie perfectly still." Considering the client's statement, which intervention would the nurse encourage the client to do? A. Participate in active joint flexion and extension exercises. B. Perform flexion exercises three times a day. C. Do range-of-motion (ROM) exercises once a day. D. Refrain from exercising until remission occurs.

ANS: A Participate in active joint flexion and extension exercises. Rationale: Active exercises (e.g.,m alternating extension, flexion, abduction, and adduction) mobilize exudate in the joints and relieve stiffness and pain. Flexion exercises alone will result in contractures. Performing ROM exercises once a day is not enough to prevent contractures. Continuing immobility until remission occurs will increase stiffness, joint pain, and the occurrence of contractures.

When assessing a client with a diagnosed "brain attack", the nurse evaluated the baseline vital signs of pulse rate of 78 beats per minute (bpm) and a blood pressure (BP) of 120/80 mm Hg. Which changes in the baseline vital signs indicate an increasing intracranial pressure (ICP)? A. Pulse 50 bpm and BP 140/60 mm Hg

ANS: A Pulse 50 bpm and BP 140/60 mm Hg Rationale: Evidence of an increasing intracranial pressure is a widening of pulse pressure and a decreased pulse rate; the changes from baseline vital signs to a pulse of 78 bpm and a BP of 140/60 mm Hg meet the criteria.

The nurse assessed a client who experienced a recent brain attack (stroke) and has a residual right-sided hemiplegia. Which rationale explains the importance of the nurse identifying mobility restrictions or neuromuscular abnormalities when assessing this client? A. Shortening and eventual atrophy of the affected muscles will occur. B. Hypertrophy of the muscles eventually will result from disuse. C. Extension rigidity can occur, making therapy painful and difficult. D. Decreased movement on the affected side predisposes the client to infection.

ANS: A Shortening and eventual atrophy of the affected muscles will occur. Rationale: Shortening and eventual atrophy of muscles occur, resulting in contractures. Muscles will atrophy, not hypertrophy, from disuse. Flexion contractions, not extension rigidity, occur. Hemiplegia does not predispose the client to infection but does predispose the client to muscle atrophy and contractures if there are delays in the beginning therapy.

The nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which clinical findings to this disease would the nurse expect the client to exhibit? Select all that apply. A. Butterfly facial rash B. Firm skin fixed to tissue C. Inflammation of the joints D. Muscle mass degeneration E. Inflammation of small arteries

ANS: A, C A. Butterfly facial rash C. Inflammation of the joints Rationale: The connective tissue degeneration of SLE leads to involvement of the basal cell layer, producing a butterfly rash over the bridge of the nose and in the cheek region. Polyarthritis occurs in most clients, with joint changes similar to those seen in rheumatoid arthritis. Firm skin fixed to tissue occurs in scleroderma; in an advanced stage the client has the appearance of a living mummy. Muscle mass degeneration occurs in muscular dystrophy; it is characterized by muscle wasting and weakness. Inflammation of small arteries occurs in polyarteritis nodosa, a collagen disease affecting the arteries and nervous system.

A home care nurse counsels a client with amyotrophic lateral sclerosis (ALS). Which information would the nurse include in their discussion? Select all that apply. A. Space planned activities throughout the day. B. Engage in social interactions with large groups. C. Request an opioid if leg pain becomes excessive. D. Anticipate the use of alternative ways to communicate. E. Use leg restraints to decrease the risk for physical injury.

ANS: A, D Rationale: Spacing activities throughout the day is a strategy to help conserve the the client's energy. The client will use alternative ways to communicate (e.g., writing, electronic devices) when speech becomes difficult because of muscle weakness. The client should avoid large groups to limit the risk for infection; respiratory complications are the leading cause of death. Clients with ALS do not use opioid medications because they may depress respirations. Lower extremity pain usually is not a problem associated with ALS. Braces and splints, not restraints, may be used.

Which interventions would the nurse include in the plan of care for a client receiving anakinra therapy for rheumatoid arthritis? Select all that apply. A. Monitor the injection site for hypersensitivity reactions every shift and PRN. B. Monitor client's blood pressure (BP) before, during, and after administration of the medication. C. Teach the client before administering the medication to report chest pain. D. Monitor client's neutrophil blood cell count before, during, and 3 months after therapy. E. Before the initial dose, teach the client to report any difficulty in breathing.

ANS: A, D, E Rationale: For the clients receiving anakinra therapy, the nurse would monitor the injection site because site reactions may occur. The nurse would also monitor the neutrophil blood count because the medication can cause a severe decrease in white blood cells, which makes the client more susceptible to infection. The nurse should teach the client to report any difficulty breathing because anakinra can cause serious respiratory infections and various types of cancer. The nurse would monitor the BP in clients who are receiving infliximab therapy. The nurse would teach clients who are receiving infliximab therapy to report chest pain.

The nurse assists a client on a rehabilitation unit after a cerebrovascular accident with residual hemiparesis to walk with the use of a cane. To help achieve the goal of safe walking with a cane, which method would the nurse teach the client? A. Shorten the stride of the unaffected extremity. B. Advance the cane and the affected extremity simultaneously. C. Lean the body toward the side with the cane when ambulating. D. Hold the cane on the same side as the affected extremity and increase the base of support.

ANS: B Advance the cane and the affected extremity simultaneously.

A client with myasthenia gravis has been receiving neostigmine and asks about its action. Which information would the nurse consider when formulating a response? A. Stimulates the cerebral cortex B. Blocks the action of cholinesterase C. Replaces deficient neurotransmitters D. Accelerates transmission along neural sheaths

ANS: B Blocks the action of cholinesterase

Which intervention related to post-cerebrovascular accident (CVA, also known as "brain attack") urinary incontinence would the nurse include in the client's plan of care? A. Insert a urinary retention catheter. B. Institute measures to prevent constipation. C. Encourage an increased intake of caffeine D. Suggest daily ingestion of a carbonated beverage.

ANS: B Institute measures to prevent constipation. Rationale: A full rectum may exert pressure on the urinary bladder, which may precipitate incontinence. Avoid use of urinary retention catheters to manage urinary incontinence initially. The use of a catheter keeps the bladder empty, which promotes atony and incontinence. Caffeine acts as a diuretic and is a urinary bladder irritant; both promote urinary incontinence. Carbonated beverages irritate the urinary bladder, which promotes urinary incontinence.

A client manifests right-sided hemianopsia as a result of a cerebrovascular accident. Which goal would the nurse include in the client's plan of care? A. Correct the client's misuse of equipment. B. Instruct the client to scan surroundings. C. Teach the client to look at the position of the left extremities. D. Provide the client with tactile stimulation to the affected extremities.

ANS: B Instruct the client to scan surroundings. Rationale: The client has lost vision from the right visual field; scanning compensates for this loss. Correct the client's misuse of equipment for clients with apraxia (inability to manipulate objects). When teaching the client to look at the position of the left extremities, neglect of the affected side increases. Provide the client with tactile stimulation to the affected extremities when the client experiences denial of the right side (unilateral neglect)

Which instruction would the nurse share with the client receiving etanercept therapy for rheumatoid arthritis? A. Report chest pain B. Report site reaction. C. Report blurry vision. D. Report difficulty breathing during infusion

ANS: B Report site reaction. Rationale: The nurse would teach a client receiving etanercept therapy to report signs of site reaction, because a site reaction is very painful. The nurse would teach a client who is receiving infliximab therapy to report chest pain. Blurry vision does not occur with etanercept. The nurse would teach a client receiving infliximab therapy to report difficulty breathing during intravenous infusion; etanercept is administered subcutaneously.

A health care provider prescribed a diagnostic workup for a client who may have myasthenia gravis. Which initial objective would the nurse establish with the client? A. "The client will adhere to the teaching plan." B. "The client will achieve psychologic adjustment." C. "The client will maintain present muscle strength." D. "The client will prepare for a possible myasthenic crisis."

ANS: C "The client will maintain present muscle strength." Rationale: Until confirming the diagnosis, the primary goal should be to maintain appropriate activity and prevent muscle atrophy. It is too early to develop a teaching plan; establishment of the diagnosis has not yet occurred. The response "achieve psychologic adjustment" is too early; the client cannot adjust with a confirmed diagnosis. The response "prepare for a possibly myasthenic crisis" is an intervention, not an objective.

Which nursing intervention is the priority for a client with stroke who is transitioned from the emergency department (ED) to other settings? A. Monitor vital signs B. Reassuring the client and family C. Assessing the level of consciousness D. Monitoring specific client manifestations of stroke

ANS: C Assessing the level of consciousness Rationale: Assessing the level of consciousness is the priority nursing action in the client with stroke and who is transitioned from the ED to other settings. Monitoring vital signs, reassuring the client and family, and monitoring specific client manifestations of stroke are ongoing nursing interventions.

After a mild brain attack, a client has difficulty grasping objects with the dominant hand. Which specific range-of-motion exercise would the nurse teach the client? A. Eversion B. Supination C. Opposition D. Circumduction

ANS: C Opposition Rationale: Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion. Strengthening the thumb facilitates grasping and holding objects in the hand. Eversion involves turning the sole of the foot outward by moving the ankle joint, which is a gilding joint. Supination involves moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body. Circumduction involves movement of the distal part of the bone in a circle while the proximal end remains fixed; circumduction is used with ball-and-socket joints, such as the shoulder and hip.

Which information would the nurse include in the discharge teaching plan for a client who sustained a cerebrovascular accident (CVA, also known as "brain attack") with residual hemiparesis and hemianopsia? A. Necessity for bed rest at home B. Use of oxygen (O2) therapy at home C. Significance of a safe environment D. Need for decreased protein in the diet

ANS: C Significance of a safe environment Rationale: Safety becomes a priority when the client has hemiparesis (paralysis on one side) and hemianopsia (abnormal visual field). Although a balance between activity and rest is important, the client does not have to maintain bed rest. O2 generally is not necessary. All the basic nutrients should be included in the diet; there is no reason to reduce protein intake.

A client who had a cerebrovascular accident begins to eat lunch. Which client behavior indicates the client may be experiencing left hemianopsia? A. The client asks to have food moved to the left side of the tray. B. The client drops the coffee cup when trying to use the right hand. C. The client ignores the food on the left side of the tray when eating. D. The client reports not being able to use the right arm to help eat meals.

ANS: C The client ignores the food on the left side of the tray when eating. Rationale: Clients with hemianopsia affecting the left field of vision cannot see whatever is in the left field of vision. Asking to have food moved to the left side of the tray may occur if the client has right hemianopsia and wishes to see better when eating. Dropping the coffee cup when trying to use the right hand may occur with right hemiparesis, not with hemianopsia. Reporting about not being able to use the right arm to help eat indicates hemiplegia, not hemianopsia.

A client with myasthenia gravis asks the nurse, "What is going to happen to me and to my family?" Which information about the anticipated disease process would the nurse incorporate when responding to the client's question? A. There is a high cure rate with proper treatment for this disease. B. This disease has a slow, progressive course, without remissions. C. The disease is a chronic illness with exacerbations and remissions. D. Myasthenia gravis has a poor prognosis, with death occuring in a few months.

ANS: C The disease is a chronic illness with exacerbations and remissions. Rationale: Myasthenia gravis is a chronic disorder with remissions and exacerbations. Emotional stress, ingestion of alcohol, and physiological stress such as infection precipitate the exacerbations. There is no cure for myasthenia gravis, but it can be managed. Exacerbations and remissions characterize this disease. The disease is chronic. Death does not occur within a short period.

Aspirin is prescribed for a client with rheumatoid arthritis. Which clinical indicators of aspirin toxicity will the nurse teach the client to report? Select all that apply. A. Bradycardia B. Joint pain C. Blood in the stool D. Ringing in the ears E. Increased urine output

ANS: C, D Blood in the stool Ringing in the ears Rationale: Blood in the stool indicates gastrointestinal irritation and may have resulted from the anticoagulant effect of aspirin. Salicylates, such as aspirin, can cause ototoxicity (affects eighth cranial nerve), which may manifest as ringing in the ears (tinnitus) or muffled hearing and it should be reported. Joint pain is not a symptom of salicylate toxicity; however, it is related to the disease process and should be minimized by the administration of aspirin. Bradycardia and increased urine output (polyuria) do not indicate salicylate toxicity.

Which clinical manifestations would the nurse identify as indicators suggesting a client has urinary retention and overflow after sustaining a cerebrovascular accident (CVA, also known as a "brain attack")? Select all that apply. A. Edema B. Oliguria C. Frequent voiding D. Suprapubic distention E. Continual incontinence

ANS: C, D C. Frequent voiding D. Suprapubic distention Rationale: With retention, the total amount of urine produced is unaffected. Atony permits the bladder to fill without being able to empty. As pressure builds within the bladder, the urge to void occurs, and the client eliminated just enough urine to relieve the pressure and the urge to void. The cycle repeats as pressure again builds. Thus small amounts are voided without emptying the bladder. As the client retains urine and the bladder enlarges, suprapubic distention occurs. Edema is a sign of fluid volume excess, not urinary retention. Oliguria (urinary output less than 400 mL/day) is a sign of acute kidney injury. Continual incontinence does not occur with urinary retention.

A client with myasthenia gravis is receiving pyridostigmine bromide to control symptoms. Recently, the client has begun experiencing increased difficulty in swallowing. Which nursing action is effective in preventing aspiration of food? A. Place a tracheostomy set in the client's room. B. Assess respiratory status after meals. C. Request for the diet to be changed from soft to clear liquids. D. Coordinate mealtimes with the peak effect of the medication.

ANS: D Coordinate mealtimes with the peak effect of the medication. Rationale: Dysphagia should be minimized during peak effect of pyridostigmine bromide, thereby decreasing the probability of aspiration. A tracheostomy set is a treatment for, rather than equipment to prevent, aspiration. Although this is a vital that the client's respiratory function be monitored, assessing the client's respiratory status will not prevent aspiration. There are insufficient data to determine whether changing the diet from soft foods to clear liquids is appropriate; also, liquids are aspirated more easily than semisolids.

To prevent the development of plantar flexion, which action would the nurse implement, when providing care for a client who sustained a cerebrovascular accident 2 days ago? A. Place a pillow under the thighs B. Elevate the knee gatch of the bed. C. Encourage active range of motion. D. Maintain the feet at right angles to the legs.

ANS: D Maintain the feet at right angles to the legs. Rationale: Maintaining the feet at right to the legs produces dorsiflexion of the feet and prevents the tendons from shortening, preventing footdrop. Placing a pillow under the thighs and elevating the knee gatch of the bed will not prevent plantar flexion; it can promote hip and knee flexion contractures. The client will not have the ability or strength to perform range-of-motion exercises unassisted at this time.