Neurosensory & Musculoskeletal

A nurse is caring for a client who has retinal detachment. Which of the following findings should the nurse expect? Photophobia Complete vision loss Flashes of bright light Cloudiness of the lens

Flashes of bright light The nurse should expect a client who has a retinal detachment to see flashes of bright light or floating dark spots in the affected eye as the retinal layers separate.

A nurse is teaching a client who has osteoporosis and has a new prescription for alendronate. Which of the following information should the nurse include in the teaching? "Take this medication with 8 ounces of milk." "Remain upright for 30 minutes after taking this medication." "Wait 1 hour after taking other medications to take alendronate." "Take vitamin C to promote absorption of this medication."

"Remain upright for 30 minutes after taking this medication." To prevent esophagitis or esophageal ulcers, which can result from alendronate therapy, the client should sit upright for 30 min after taking this medication.

A nurse is caring for a client in balanced suspension skeletal traction who reports intermittent muscle spasms. Which of the following actions should the nurse take first? Reposition the client. Check the position of the weights and ropes. Administer a muscle relaxant. Provide distraction.

Check the position of the weights and ropes. The first action the nurse should take when using the nursing process is to assess the client. The nurse should first check the position of the weights and ropes to investigate the cause of the muscle spasms. The weights might be too heavy, or the nurse might need to realign the client.

A nurse is performing a pain assessment on a postoperative client. Which of the following should the nurse use to determine the severity of the client's pain? Client's vital sign changes Client's report of the type of pain Client's nonverbal communication Client's report of pain on a pain scale

Client's report of pain on a pain scale The nurse should use a client's report of pain on a standardized pain scale to determine the severity of the client's pain.

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take? Apply a pressure dressing to the site for 8 hr. Restrict the client's fluid intake for 24 hr. Ensure that the client lies flat for up to 12 hr. Inform the client that neck stiffness is an expected outcome of the procedure.

Ensure that the client lies flat for up to 12 hr. The client should lie flat for up to 12 hr to prevent cerebrospinal fluid leakage from the puncture site, which can cause a headache.

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take? Assess hourly for a spike in blood pressure. Keep the client on bed rest. Keep a padded tongue blade at the bedside. Establish IV access.

Establish IV access. The nurse should plan to establish IV access with a large-bore catheter and administer 0.9% sodium chloride if seizures are imminent. If the client is stable, the nurse should initiate a saline lock.

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? Hypoactive deep-tendon reflexes Ascending paralysis Intention tremors Increased lacrimation

Intention tremors Clients who have multiple sclerosis are at risk for motor dysfunction, with intention tremors, poor coordination, and loss of balance.

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority? Maintain a PaCO2 of approximately 35 mm Hg. Provide small doses of fentanyl via IV bolus for pain management. Measure body temperature every 1 to 2 hr. Reposition the client every 2 hr.

Maintain a PaCO2 of approximately 35 mm Hg. The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority intervention is to maintain the PaCO2 at 35 to 38 mm Hg to prevent hypercarbia and subsequent vasodilation that can lead to an increase in intracranial pressure.

A Nurse is caring for a client who is 72 hours postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take? Remind the client that the surgery removed the limb Change the dressing on the client's residual limb. Request a prescription for gabapentin for the client. Elevate the client's residual limb above heart level.

Request a prescription for gabapentin for the client. The nurse should request a prescription for a nonopioid medication to help minimize phantom limb pain. Gabapentin is an oral antiepileptic medication that is effective for treating sharp, burning, phantom limb pain.

A nurse is providing teaching for a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?

The nurse should teach the client to sit with the hips at a 90 degree angle or less with the knees slightly lower than the hips to avoid hip dislocation.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect? Aphasia Right-sided neglect Impulsive behavior Inability to read

Impulsive behavior The nurse should expect clients who had a right hemispheric stroke to demonstrate impulsive behavior, poor judgment, and lack of awareness of neurologic deficits.

A nurse in the emergency department is assessing a client who reports sudden, severe eye pain with blurred vision. The provider determines the client has primary angle-closure glaucoma. Which of the following medications should the nurse administer? Osmotic diuretics via IV bolus Mydriatic ophthalmic drops Corticosteroid ophthalmic drops Epinephrine via IV bolus

Osmotic diuretics via IV bolus The nurse should expect to administer prescribed osmotic diuretics, such as mannitol, to reduce intraocular pressure and prevent damage to the eye.

A nurse is assessing a client who has a possible head injury following a motor-vehicle crash. The nurse should recognize that which of the following findings indicates increasing intracranial pressure? Restlessness Dizziness Hypotension Fever

Restlessness Behavioral changes, such as restlessness and irritability, are early manifestations of increased intracranial pressure.

A nurse is teaching a client who has Parkinsons disease and is precribed carbidopa-levodopa. Which of the following statements indicates an understanding of the teaching? "I should expect an increase in my blood pressure while taking this medication." "I should take this medication 2 hours after meals to increase absorption." "I should expect that this medication can cause me to be drowsy." "I should expect this medication to be effective within 48 hours."

"I should expect that this medication can cause me to be drowsy." Drowsiness is a known adverse effect of carbidopa-levodopa; therefore, clients are taught to avoid heavy machinery and driving if they experience drowsiness.

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?

Monitor pulse oximetry findings The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor the client's oxygen saturation to identify respiratory compromise as soon as possible.

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?

Stroke the client's inner thigh. The nurse should stimulate micturition by stroking the client's inner thigh. Other techniques include pinching the skin above the groin and providing digital anal stimulation.

A nurse is teaching an assistive personnel (AP) about providing care to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? Avoid applying antiembolism stockings to the affected leg. Have the client lean forward when moving from a sitting to a standing position. Discourage the client from sitting in a wheelchair with the back reclined. Place an abductor pillow between the client's legs when turning the client.

Place an abductor pillow between the client's legs when turning the client. The nurse should inform the AP that a client who had a total hip arthroplasty should maintain the hip in abduction following surgery to reduce the risk of dislocating the affected hip. The AP should place an abductor pillow between the client's legs when turning the client to keep the hips in abduction.

A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell while in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer? Tissue plasminogen activator Recombinant factor VIII Nitroglycerin Lidocaine

Tissue plasminogen activator Tissue plasminogen activator is a thrombolytic agent that should dissolve the blood clot that caused the stroke.

A nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicated that the client understand the teaching? "I will ask my partner to give the injection in the same spot each time." "I will avoid going to the store when it is crowded." "I will see relief of my symptoms in about 1 week." "I will exercise rigorously while taking this medication."

"I will avoid going to the store when it is crowded." Clients who are prescribed this medication are instructed to avoid crowds and individuals who have infection.

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include? "Move your head slowly to decrease vertigo." "Apply warm packs to the affected ear during acute attacks." "Increase your intake of foods and fluids high in salt." "Take corticosteroids during acute attacks."

"Move your head slowly to decrease vertigo." The nurse should instruct the client to use slow head movements to keep from worsening the vertigo.

A nurse is reviewing postoperative instruction with a client following cataract surgery. Which of the following statements indicated an understanding of the instructions? "I should call my doctor if my vision gets worse." "I will take aspirin for eye discomfort." "I can blow my nose to clear out any drainage." "I can lift objects up to 20 pounds."

"I should call my doctor if my vision gets worse." The client should expect an improvement in vision after the surgery, so the nurse should instruct the client to report negative changes in vision immediately.

A nurse is providing teaching for a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements by the family indicates an understanding of the teaching? "There is a test for Alzheimer's disease that can establish a reliable diagnosis." "The goal of medication therapy is to reverse the degenerative changes that can occur in brain tissue." "Early manifestations of Alzheimer's disease include mild tremors and muscular rigidity." "The medications that treat Alzheimer's disease can help delay cognitive changes."

"The medications that treat Alzheimer's disease can help delay cognitive changes." Medications that treat Alzheimer's disease enhance the availability of acetylcholine, which can slow cognitive decline in some clients.

A nurse in an emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images should the nurse recognize as a comminuted fracture?

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A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take? Assess the client's neurologic status every 8 hr. Initiate droplet precautions. Check capillary refill at least every 4 hr. Place the client in a well-lit environment.

Check capillary refill at least every 4 hr. The nurse should perform a complete vascular assessment at least every 4 hr to monitor for vascular compromise.

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? Glasgow Coma Scale score of 15 Intracranial pressure reading of 15 mm Hg Ecchymosis at base of skull Clear drainage from nose

Clear drainage from nose Clear drainage from the nose indicates that cerebrospinal fluid is leaking from the skull fracture. This places the client at risk for meningeal infection because micro-organisms have access to the cranium through the nose and the tear in the dura. The nurse should report this finding to the provider.

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect? (Select all that apply) Crepitus with joint movement Decreased range of motion of the affected joint Low-grade fever Spongy tissue over the joints Joint pain that resolves with rest

Crepitus with joint movement is correct. Osteoarthritis is a degenerative joint disease. Crepitus, a grating sound, is an expected finding with clients who have osteoarthritis as loosened bone and cartilage move around in the fluid inside the joint. Decreased range of motion of the affected joint is correct. Decreased range of motion is an expected finding with clients who have osteoarthritis because the client's pain limits movement. Low-grade fever is incorrect. Osteoarthritis does not cause systemic manifestations. Rheumatoid arthritis causes many systemic manifestations, including low-grade fever, weakness, anorexia, and paresthesias. Spongy tissue over the joints is incorrect. Spongy joint tissue is an expected finding with rheumatoid arthritis, which is an inflammatory disease, not a degenerative disease. Joint pain that resolves with rest is correct. Joint pain that resolves with rest is an expected finding with clients who have osteoarthritis. A client who has osteoarthritis experiences increased pain with activity and decreased pain with rest.

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level CS. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first? Administer hydralazine via IV bolus. Loosen the client's clothing. Empty the client's bladder. Elevate the head of the client's bed.

Elevate the head of the client's bed. These assessment findings indicate that the client is experiencing autonomic dysreflexia and is at greatest risk for possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension.

A nurse is caring for a client who is recovering from a stroke and has right- sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions? Check the client's cheek on the affected side after meals to be sure no food remains there. Encourage the client to sit upright with their head tilted slightly forward during meals. Provide the client with eating utensils that have large handles. Remind the client to look consciously at both sides of their meal tray.

Remind the client to look consciously at both sides of their meal tray. Clients who have right-sided homonymous hemianopsia have lost the right visual field of both eyes and might only eat the food they are able to see on the left half of the meal tray. Therefore, the nurse should remind the client to look at both sides of his meal tray to help compensate for the visual loss.

A nurse is teaching a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the clients medication teaching plan? Rinse with antiseptic mouthwash instead of using dental floss. Use an over-the-counter antihistamine if a rash develops. Slowly taper the medication after 6 consecutive months without seizure activity. Take medications at a consistent time each day to maintain therapeutic blood levels.

Take medications at a consistent time each day to maintain therapeutic blood levels. The nurse should teach the client to take antiepileptic medications on a regular schedule to maintain therapeutic blood levels and achieve the maximum effect.

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect? Unilateral joint involvement Ulnar deviation Fractures of the spine Decreased sedimentation rate

Ulnar deviation A client who has rheumatoid arthritis can experience inflammation in the hand joints that can make them susceptible to deformity from daily use. Ulnar deviation, or lateral deviation of the fingers, can occur from opening jars and other similar motions.