evolve neuromuscular system

What should the nurse consider as the goal of therapy when administering allopurinol (Zyloprim) to a client with gout?

Decrease uric acid production

A client who has paraplegia often loses calcium from the skeletal system. The nurse concludes that a factor that contributes to calcium loss in this client is:

Decreased activity

A nurse is assessing a client with a diagnosis of dry age-related macular degeneration. Which ocular symptom should the nurse expect the client to report?

Loss of central vision

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurological examination. What should the nurse document in the client's medical record?

"Exhibits a positive Babinski sign."

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" The nurse's best response is:

"The prognosis is variable; most individuals experience remissions and exacerbations."

Immediately after cataract surgery a client complains of feeling nauseated. The nurse should:

Administer the prescribed antiemetic

Postoperatively, a client complains about a variety of minor environmental factors, frequently changes positions, and avoids eye contact. The nurse responds to these observations by stating, "Let me get you some cold water and your pain pill, and you'll be much better." The nurse's response demonstrates:

An inappropriate interpretation of the assessment findings

A client who had a brain attack (CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. The nurse documents this response as

Anomia

After a client has spinal surgery, it is essential that the nurse:

Assess the client's feet for circulation and sensation

The nurse teaches a client who developed degenerative joint disease of the vertebral column positioning techniques, including turning from back to side, keeping the spine straight. The nurse explains that the least effort will be exerted if the client crosses the arm over the chest and:

Bends the top knee to the side to which the client is turning

A client is admitted to the emergency department with a head injury. Assessment findings include restlessness, cool and damp skin, equal and reactive pupils, and the ability to move all extremities on command. A computed tomography (CT) scan shows a subdural hematoma. The nurse understands that this condition means there is:

Blood between the dura mater and the arachnoid layer

A client who is diagnosed as having a herniated nucleus pulposus complains of pain. The nurse concludes that the pain is caused by the:

Compression of the spinal cord by the extruded nucleus pulposus

The nurse evaluates that the teaching about myasthenic and cholinergic crises is understood when a client who is diagnosed with myasthenia gravis states that a characteristic common to both crises is:

Difficulty breathing

A client sustains a fracture of the femur after jumping from the second story of a building during a fire. The client is placed in Buck's traction until an open reduction and internal fixation is performed. The client keeps slipping down in bed. To alleviate this problem the nurse should:

Elevate the foot of the bed

A nurse is caring for a client who will have a below-the-knee amputation with an immediate postoperative prosthesis. The client asks the nurse the advantage of having an immediate prosthesis. What should the nurse explain is the advantage?

Encourages a normal walking pattern.

A client is admitted to the hospital with weakness in the right extremities and speech that is slightly slurred. A diagnosis of brain attack (CVA) is suspected. During the first 24 hours after symptom onset, the priority nursing intervention is to:

Evaluate motor status

A client who had a brain attack (cerebral vascular accident) several months ago is readmitted to the hospital for a complication of immobility. The nurse reviews the client's laboratory test results, obtains vital signs, and performs a physical assessment. Data reveal elevated white blood cells (WBCs), fever of 101.2, and crackles upon auscultation of the bases bilaterally. Based on the results of the client's work-up, which prescribed medication should the nurse consider the priority at this time?

Levofloxacin (Levaquin)

A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern?

Extending

A client manifests right-sided hemianopsia as a result of a brain attack (CVA). The nurse develops a plan of care and includes

Instruct the client to scan surroundings

An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action?

Interview the client without the presence of family members.

A client who is legally blind is admitted to the hospital for surgery. What nursing action is most appropriate when caring for this client?

Keep the furniture in the same location in the room

A client who had an open reduction and internal fixation of a fractured ankle is being discharged. Which behavior indicates the need for further instruction about the use of crutches?

Leaning axillae on the crutches to support the body's weight

A client is scheduled for a laminectomy. What should the nurse review with this client preoperatively?

Logrolling technique

A primary health care provider prescribes a diagnostic workup for a client who may have myasthenia gravis. The initial nursing goal for the client during the diagnostic phase is that the client will:

Maintain present muscle strength

A client with a history of seizures is admitted with a partial occlusion of the left common carotid artery. The client has been taking phenytoin (Dilantin) for 10 years. When planning care for this client, what should the nurse do first?

Obtain a history of seizure type and incidence.

A client is admitted to the hospital for cranial surgery. The nurse develops the preoperative plan of care and includes:

Obtaining the client's consent for shaving the head

After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." The nurse should:

Perform a complete pain assessment

The bed alarm is ringing because of an elderly client attempting to get out of bed. A nurse enters the room and finds the client agitated and confused. The family member is upset and states, "He has never been like this. I don't know what to do." After getting the client back into bed, which of these nursing actions are appropriate?

Request the nursing assistant to stay with the client, while the nurse calls the primary health care provider

After three months of rehabilitation following a craniotomy, a client still is having some motor speech difficulty. What should the nurse do to promote the client's use of speech?

Respond to the client's efforts of speaking.

An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. The nurse explains that the abilities that will be affected include:

Stating wishes verbally

A client with a 5-year history of myasthenia gravis is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. The nurse expects what client response?

Strength decreases with repeated muscle use

A client with a history of tuberculosis reports difficulty hearing. Which medication should the nurse consider is related to this response?

Streptomycin

A client with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. The nurse explains the purpose is to:

Support the soft tissue and minimize swelling

A client is fitted for and receives a prosthesis after an above-the-knee amputation. A week later the client states, "I feel so much better." What is the reason why most clients report an improved self-image after using a prosthesis?

Their improved functional abilities

A client just has been diagnosed with multiple sclerosis. The client is upset and asks the nurse, "Am I going to die?" What is the nurse's best response?

There is a variable prognosis, with most individuals experiencing remissions and exacerbations."

A client with a head injury is admitted to the hospital. Which client response indicates increasing intracranial pressure?

Widening pulse pressure