Prep U questions chapter 64

The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction?

Assess the blood pressure and heart rate

A nurse assesses an older adult's risk for pressure ulcers based on the understanding that which of the following increases the client's susceptibility?

Diminished dermal collagen

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

Fatigue

The diagnosis of multiple sclerosis is based on which test?

Magnetic resonance imaging (MRI)

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 with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective?

"I need to allow my arms and hands to support my body weight."

The nurse is assisting a patient in assuming a side-lying position. What intervention would be best for the nurse to provide?

Place the uppermost hip slightly forward in a position of slight abduction

What diet can the nurse recommend to a patient with hypoproteinemia that spares protein?

A diet high in carbohydrates

The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform?

Apply warm packs to the affected area

The nurse is assessing a client with sudden bilateral lower extremity weakness and dyskinesia. The client reports accompanying numbness and tingling episodes. Which question will the nurse ask the client to help determine the reason for the client's symptoms?

"Have you had a recent illness?"

The nurse is initiating a bladder-training schedule for a patient. What intervention can be provided for optimal success? (Select all that apply.)

- Encourage the patient to wait 30 minutes after drinking a measured amount of fluid before attempting to void - Give up to 3,000 mL of fluid daily - Teach bladder massage to increse intr-abdominal pressure

A client is receiving mitoxantrone for treatment of secondary progressive multiple sclerosis (MS). This client should be closely monitored for

Leukopenia and cardiac toxicity

A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty boots. The nurse notes a circular wound 2 cm × 2 cm × 0.25 cm on the posterior aspect of the calf. What most likely caused the client's skin breakdown?

Specialty boots

The nurse is fitting a patient for crutches that are required for an ankle injury. What quick method can the nurse use to measure so that the crutches will be of appropriate height?

Use the patient's height and subtract 16 inches