Prep U: Chapter 64 Adult Nursing

The nurse is talking with the mother of a client who is diagnosed with a traumatic brain injury. The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction, made by the nurse, is most correct?

"The client may be experiencing a change in affect due to the brain injury."

A patient diagnosed with meningitis would be expected to exhibit which of the following clinical manifestations? Select all that apply.

-Nuchal rigidity -Positive Kernig's sign -Positive -Brudzinski's sign -Photophobia

A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply.

-presence of pressure ulcers on the client -overall risk of developing pressure ulcers -potential areas of pressure ulcer development

A nurse is reviewing a patient's laboratory test results. Which serum albumin level would lead the nurse to suspect that the patient is at risk for pressure ulcers?

2.5 g/mL

A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document?

Abduction

A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse?

Accept the patient's behavior and do not take it personally.

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine

An elderly woman diagnosed with osteoarthritis has been referred for care. The client has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention will best promote the client's mobility?

Administer an analgesic as prescribed to facilitate the client's mobility.

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements?

Antibodies are removed from the plasma.

The nurse is admitting a client into the rehabilitation unit after an industrial accident. The client's nursing diagnoses include disturbed sensory perception and the nurse identifies that he has decreased strength and dexterity. The nurse should know that this client may need what to accomplish self-care?

Appropriate assistive devices

Which drug should be available to counteract the effect of edrophonium chloride?

Atropine

Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis?

Controlling seizures and increased intracranial pressure

A nurse is assessing a client who will be discharged home after rehabilitation for a stroke. The nurse is questioning the client about his instrumental activities of daily living (IADLs). Which of the following would the nurse address?

Cooking

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test?

Edrophonium (Tensilon)

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?

Facial distortion and pain

While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?

Facial pain in the areas of the fifth cranial nerve

Which is often the most disabling clinical manifestation of multiple sclerosis?

Fatigue

A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use?

Functional Independence Measure

The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?

Headache and nuchal rigidity

Which is the most common cause of acute encephalitis in the United States?

Herpes simplex virus (HSV)

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds

A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?

Initiate isolation precautions.

An older adult experienced a cerebrovascular disease 6 weeks ago and is currently receiving inpatient rehabilitation. The nurse is coaching the client to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the client performing?

Isometric

A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care?

Lubricating the skin with a non-irritating lotion

The nurse is educating a client with myasthenia gravis about medications. The nurse is sure to include which of the following?

Medications must be taken on time.

Which is the primary vector of arthropod-borne viral encephalitis in North America?

Mosquitoes

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis?

Neck flexion produces flexion of knees and hips

A nurse is performing passive range of motion to a client's upper extremities. The nurse touches the client's thumb to each fingertip on the same hand. The nurse is performing which of the following?

Opposition

When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process?

Patient

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions?

Renal

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk?

Serum albumin

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?

Suction machine with catheters

A patient learning to ambulate with crutches advances both crutches and then lifts both feet, moving them forward and landing them in front of the crutches. The patient then repeats this motion. The nurse identifies this as which type of crutch gait?

Swing-through

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?

Tensilon test

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?

Trochanter roll

A client is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility?

Turning the client every 2 hours and providing a low-air-loss mattress

A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is given crutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client?

Whether the client needs to navigate stairs routinely at home

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in an air-conditioned room.

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called:

stress incontinence.

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?

Positive Brudzinski's sign

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?

Alternatively patch one eye every 2 hours.

Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?

Creutzfeldt-Jakob disease