Reproductive/Neuro ATI practice

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

"Have you had a recent influenza infection?"

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

Apply downward pressure while the client shrugs his shoulders upward.

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication?

Ask the client to take a few sips of water.

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves.

A nurse is speaking with a 35-year-old client who has fibrocystic disease of the breasts. At which of the following times should the nurse inform the client that manifestations are most evident?

Before menstruation begins

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

Bradycardia Nonreactive dilated pupils

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

Bradykinesia

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Brudzinski's sign

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

Paraplegia

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Place a pillow under the client's head.

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.

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 mm Hg 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.

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 actions should the nurse take first?

Place the client in a sitting position

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Place the client on his side.

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is 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

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

A nurse is evaluating a client's laboratory results. The nurse should recognize that an increase in the client's prostate specific antigen (PSA) laboratory value is indicative of which of the following diagnoses?

Prostatic cancer

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)

Provide a suction setup at the bedside Elevate the side rails near the head when the client is in bed Place the bed in the lowest position Keep an oxygen setup at the bedside

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?

Shivering

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

A nurse is caring for a client who is 1 day postoperative following a mastectomy. Which of the following exercises should the nurse assist the client to perform on the affected side? (Select all that apply.)

Squeezing a rolled washcloth Flexing and extending her hand Flexing and extending her elbow

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

The client's bladder becomes distended.

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Use pillows to keep heels off the bed surface. Minimize skin exposure to moisture

A nurse is caring for a client who is postoperative following a right-sided mastectomy and has a drain connected to a portable drainage evacuator. Which of the following actions should the nurse?

Take blood pressures on the client's non-affected arm.

A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.)

Use sterile technique when preparing the irrigation solution. Ensure the drainage tubing is patent and without obstruction. Notify the surgeon if the urine is bright red in appearance or has large clots.

A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider?

WBC 2300/mm3

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Weakness

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

Widened pulse pressure

A nurse is providing teaching to a client who has a new diagnosis of testicular cancer. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Close male relatives are at an increased risk of developing testicular cancer. Testicular cancer typically occurs between ages 15 and 35.

A nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform with her right hand?

Combing her hair

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

Headache Slurred speech Pupillary changes Disorientation

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Loosen restrictive clothing. Place a pillow under the client's head.

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

Severe headache

A nurse is providing breast self-examination teaching to a client who is menopausal. Which of the following statements should the nurse identify as an indication that the teaching was effective? (Select all that apply.)

"I don't have to lie down to check my breasts. I can stand in the shower." "It is important to press firmly when feeling my breasts to detect changes." "Since I no longer have periods, I can perform an examination at any time of the month." "I will make sure to feel for changes in my underarm area."

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). 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."

A nurse is teaching a client who has fibrocystic breast condition (FBC) about strategies to minimize discomfort. Which of the following instructions should the nurse include in the teaching?

"Limit your dietary intake of salt prior to menses."

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

"Move objects away from the client."

A nurse is teaching the family of a client who is receiving treatment for a 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."

A nurse is preparing to administer clonazepam 1.5 mg PO in 3 equally divided doses every 8 hr for a client who has seizures. The amount available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

1

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

Elevate the head of the bed.

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 client's plan of care?

Ability to self-feed with the use of adaptive equipment

A nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions?

Carbon monoxide poisoning

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Check the tubing for kinks.

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

A nurse is caring for a client who has myasthenia gravis. The nurse should recognize that this disease is caused by which of the following types of hypersensitivities?

Cytotoxic

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

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 outcomes should the nurse expect to see?

Decreased tremors

A nurse in the emergency department is caring for a client who has 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

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?

Difficulty starting the flow of urine

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

Difficulty voiding

A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?

Do not apply heat to the area of irradiation.

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

Elevate the head of the bed to 30°

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

Encourage fluid intake at and between meals.

A nurse is caring for a client who reports a severe headache following a lumbar puncture. Which of the following actions should the nurse take?

Encourage oral fluids.

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Establish a plan of care with the client that sets attainable goals.

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.

A nurse is teaching a group of male adolescents about testicular self-examination. Which of the following information should the nurse include?

Examine the testicles after a bath or shower.

A nurse is preparing a client for a radiation treatment who is postoperative following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the treatment?

Fatigue

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer?

Finasteride

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? (Select all that apply.)

Hypotension Absence of bowel sounds Weakened gag reflex

A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions?

Hemolytic

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?

Hemorrhage

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?

Hemorrhagic stroke

A nurse is providing teaching to a client who has a new prescription for tamoxifen to treat breast cancer. The nurse should include that which of the following is an adverse effect of this medication?

Hot flashes

A nurse is teaching for a client who is to begin taking tamoxifen to treat breast cancer. The nurse should instruct the client to expect which of the following findings as an adverse effect of the medication?

Hot flashes

A nurse is caring for a client who is diabetic and reports a headache, restlessness, fatigue, and hunger. Then nurse should identify that the client is likely experiencing which of the following conditions?

Hypoglycemia

A nurse is providing an education program about dietary interventions to reduce the risk for prostate cancer. Which of the following information should the nurse include?

Increase fatty fish in the diet

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Increase fluid intake.

A nurse is performing a neurological assessment for a client 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

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

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?

Pale pink

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.

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.

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)

Muscle distortion Pain behind the ear Impaired taste

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care?

Obtain IV access.

A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?

Output of burgundy colored urine

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.

A nurse is developing a plan of care for a client following a lumbar puncture. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Provide oral fluids. Monitor for nausea. Check level of consciousness. Check sensation in the toes.

A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse take to maintain privacy for the client?

Pull the curtains around the client's bed.

A nurse is preparing to administer an osmotic diuretic 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.

A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?

Refusing to look at the dressing or surgical incision

A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

Remind the client he might feel a constant urge to void.

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

Restlessness

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

Restlessness

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side.

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?

Use log rolling to reposition the client.