Exam 3
A client who works as a truck driver, delivering food to grocery stores, sustains a lower back strain while lifting boxes of canned goods. During treatment, the nurse provides information to the client regarding lower back care. Which statement by the client indicates a need for further teaching? "I can sleep in my recliner." "I shouldn't sit in low couches and chairs." "I need to sleep on a bed with a firm mattress." "I'll start eating more fiber and drinking more water."
"I can sleep in my recliner." RATIONALE: Lower back care measures are focused on preventing strain on the muscles of the back and, therefore, injury. The client is instructed to sleep on a firm mattress and to avoid sleeping in a chair or partially reclined position. The client should also avoid sitting in low couches and chairs, which cause strain on the lower back muscles, particularly when the occupant moves from the sitting position to a standing one. A diet high in fiber and fluids will result in softer bowel movements, helping eliminate the need for straining.
A child riding a skateboard loses his balance; as he falls, he uses his arm to break the fall, fracturing his ulna. A plaster cast is applied to the boy's arm, and the child's mother is instructed in cast care and complications associated with the cast. Which statement by the mother indicates a need for further teaching? "I need to keep the arm with the cast elevated on a pillow." "The cast needs to dry, so we need to be careful how we touch it." "I need to make sure that he doesn't put anything inside the cast." "I should expect to see swelling, and he'll have pain in the hand below the cast. The swelling might even cause some numbness."
"I should expect to see swelling, and he'll have pain in the hand below the cast. The swelling might even cause some numbness." RATIONALE: After a cast is applied, the affected limb is elevated on pillows or a similar support for at least the first 24 to 48 hours to help prevent swelling. When a wet cast is handled, care is taken to avoid denting it, which might result in the formation of pressure points. The parent should not allow the child to put anything inside the cast. Movement and sensation in the visible part of the extremity are checked frequently. Pain, swelling, discoloration, lack of pulsation and warmth, and numbness or tingling are not expected and should be reported immediately to the primary health care provider as signs/symptoms of circulatory impairment.
Aneurysm precautions are instituted for a hospitalized client with a cerebral aneurysm. Which nursing interventions should the nurse include in the precautions? Select all that apply. Administering stool softeners to the client Limiting the number of visitors and keeping visits short Encouraging restful activities such as listening to quiet music Keeping the client's room well lit, especially during the daytime hours Encouraging the client to dress in street clothes and shoes every day
Administering stool softeners to the client Limiting the number of visitors and keeping visits short Encouraging restful activities such as listening to quiet music RATIONALE: The focus of nursing care for a client with a cerebral aneurysm is careful client monitoring and implementation of aneurysm precautions. The purpose of these precautions is to maintain a stable perfusion pressure. These precautions include bed rest (if prescribed) in a quiet private room (a client who is allowed out of bed is not allowed to bend over), encouraging restful activities such as listening to quiet music, keeping the room slightly darkened, administering stool softeners to prevent straining, and discouraging the use of the Valsalva maneuvers. The nurse assesses the client closely for changes in neurological status, limits the number of visitors, and keeps visits short.
A client being treated for a middle ear infection is unable to close the left eye. After an assessment the client is diagnosed with Bell's palsy. Which information should the nurse give to the client? The eye paralysis is permanent. Artificial tears should be instilled into the left eye. It usually takes about 6 months for the disease to resolve. Intravenous corticosteroids are required, along with intensive physical therapy of the facial muscles.
Artificial tears should be instilled into the left eye. RATIONALE: Bell's palsy is an acute paralysis of cranial nerve VII that may occur as a result of trauma, infection, hemorrhage, meningitis, or a tumor. It results in paralysis of one side of the face. Recovery usually occurs in a few weeks, without residual effects. Eye care is essential because the client is unable to blink or close the eyelid on the affected side. The client is instructed to instill artificial tears in the eye and to place a patch over the eye when outdoors and at night to protect it from abrasion, wind, and light damage. Corticosteroids are not normally prescribed, and intensive physical therapy is not necessary.
Which factors increase the risk of osteoporosis? Select all that apply. Obesity Late menopause Cigarette smoking Sedentary lifestyle African heritage Family history of osteoporosis
Cigarette smoking Sedentary lifestyle Family history RATIONALE: Osteoporosis is a metabolic disease characterized by bone demineralization, with loss of calcium and phosphorus salts leading to bone fragility and an increased risk for fractures. Risk factors include cigarette smoking; early menopause; excessive use of alcohol; family history; female sex; increasing age, insufficient intake of calcium, sedentary lifestyle; a thin, small frame; and European or Asian descent
A client is brought to the emergency department after sustaining a fall, complaining of severe pain in the right arm. The nurse carefully cuts off the clothing that is covering the arm and notes an open wound with bone protruding from it. Which action should the nurse take immediately? Covering the open area with a sterile dressing Obtaining a prescription for pain medication Placing the cut-off shirt sleeve over the open area Irrigating the open area with half strength hydrogen peroxide
Covering the open area with a sterile dressing RATIONALE: If the client has sustained an open fracture, the nurse must cover the open area with a dressing, preferably sterile. The shirt sleeve would not be used, because it is unclean and presents a risk for infection. Obtaining a prescription for pain medication is the next action after covering and protecting the open area. The nurse would not irrigate the open area without a prescription to do so.
An anticholinesterase medication has been prescribed for a client with myasthenia gravis, and the nurse teaches the client how to recognize a cholinergic crisis. Which should the nurse tell the client is a sign/symptom of this type of crisis? Diarrhea Bladder incontinence Difficulty swallowing Decreased urine output
Diarrhea Cholinergic crisis is caused by overmedication with anticholinesterase medication. Signs/ symptoms include restlessness, weakness, dysphagia, dyspnea, nausea and vomiting, diarrhea, abdominal cramps, blurred vision, pallor, facial muscle twitching, pupil constriction, and hypotension. Interventions include withholding the anticholinesterase medication. Atropine sulfate, the antidote for an overdose of anticholinesterase medication, may be administered. Myasthenic crisis is an acute exacerbation of the disease. Signs/ symptoms include increased pulse, quickened respiration, increased blood pressure, anoxia, cyanosis, bowel and bladder incontinence, decreased urine output, and absence of cough and swallow reflexes. Interventions for this type of crisis include increasing the dosage of anticholinesterase medication.
The nurse provides home care instructions to a client who has been fitted with a halo traction device. Which instructions should the nurse include on the list? Select all that apply. Eat foods high in protein and calcium. Remember that a clicking sound heard at the pin site is normal. Tighten the ring bolts on the vest with a wrench if they loosen. Each day, check the skin under the vest with a flashlight for breakdown. Check the tightness of the vest by ensuring that one finger can be placed between it and the skin. When getting out of bed, roll onto the side and push up from the mattress with the arms.
Eat foods high in protein and calcium. Each day, check the skin under the vest with a flashlight for breakdown. Check the tightness of the vest by ensuring that one finger can be placed between it and the skin. When getting out of bed, roll onto the side and push up from the mattress with the arms. RATIONALE: The client wearing a halo traction device must be provided with instructions on care to ensure safety and maintenance of intactness of the device. Foods high in protein and calcium should be consumed, because they will promote healing. The client is taught to clean the pin site daily; to check the skin under the vest daily for breakdown, using a flashlight; and to notify the primary health care provider if redness, swelling, drainage, broken skin, pain, tenderness, or a clicking sound is noted at the pin site. These findings may indicate infection or disruption or displacement of the pins. Additionally, if the ring bolts on the vest loosen, the primary health care provider is notified; the client must never attempt to tighten the ring bolts on his or her own. The tightness of the vest may be checked by ensuring that one finger can be placed between it and the skin. The metal frame of the device is never pulled on or used to reposition the client. When getting out of bed, the client is taught to roll onto the side and push up from the mattress with the arms.
Which are characteristics of the Brown-Séquard syndrome? Select all that apply. The injury affects the entire spinal cord. It is a type of injury that results from penetrating injuries. Pain sensation is lost on the same side of the body as the injury. Motor function is lost on the same side of the body as the injury. Light touch sensation is affected on the opposite side of the body from the injury. Question 1 of 1
It is a type of injury that results from penetrating injuries. Motor function is lost on the same side of the body as the injury. Light touch sensation is affected on the opposite side of the body from the injury. RATIONALE: Brown-Séquard syndrome is a type of spinal cord injury syndrome that results from penetrating injuries that cause hemisection of the spinal cord or injuries that affect half of the spinal cord. Motor function, proprioception (position sense), vibration, and deep touch sensations are lost on the same side of the body as the injury (ipsilateral). On the opposite side of the body (contralateral) from the injury, the sensations of pain, temperature, and light touch are affected due to spinal nerve tract crossing.
A client who has had a stroke is experiencing left-sided unilateral neglect syndrome. Which intervention should the nurse include in the plan of care to manage this effect of the stroke? Instructing the client to primarily scan the left side of the environment Encouraging the client to use the right side only because it is the unaffected side Informing the client that it is best to visualize the environment by looking straight ahead as much as possible Moving personal items to the affected side as the client demonstrates ability to compensate for the neglect
Moving personal items to the affected side as the client demonstrates ability to compensate for the neglect RATIONALE: Neglect syndrome, also known as unilateral neglect, is a syndrome in which the client is unaware of his or her paralyzed side. Management of the disorder includes helping the client acknowledge the affected side as being integral to his or her self. Once the client demonstrates an ability to compensate for the neglect, the nurse moves the client's personal items to the affected side so that the client will use the neglected side. The nurse also places the client's personal objects within his or her visual field and teaches the client to touch and use both sides of the body. The client with visual problems is taught to turn the head from side to side to scan the environment.
The nurse is watching for indications of autonomic dysreflexia in a client who sustained a spinal cord injury in a fall from a roof. Which sign/symptom of this complication should the nurse monitor closely? Constricted pupils Tachycardia Hypotension Nasal stuffiness
Nasal stuffiness RATIONALE: Autonomic dysreflexia, a complication of spinal cord injury, is a neurological emergency and must be treated immediately to prevent hypertensive stroke. It generally occurs after spinal shock resolves in the presence of injuries above T6 and in cervical lesions. It is commonly caused by visceral distention resulting from bladder distention or fecal impaction. Clinical manifestations include sudden onset of severe throbbing headache, severe hypertension, bradycardia, flushing above the level of injury, pale extremities below the level of injury, nasal stuffiness, nausea, dilated pupils, blurred vision, sweating, piloerection (gooseflesh), restlessness, and a feeling of apprehension.
A client is fitted with a cast after being hit by a car and sustaining a fracture of the left leg. The client has been hospitalized, and the nurse is monitoring the client for other injuries that may have resulted from the accident. Three hours after admission to the surgical unit, the client calls the nurse to report numbness and tingling in the toes of the left foot. Which action should the nurse take? Administer pain medication. Notify the primary health care provider. Tell the client that the signs/symptoms will be reassessed in 1 hour. Tell the client that this is expected because of the swelling from the fracture.
Notify the primary health care provider.
Which interventions apply in the care of a child who is experiencing a seizure? Select all that apply. Time the seizure. Restrain the child. Stay with the child. Insert an oral airway. Place the child in a supine position. Loosen clothing around the child's neck.
Time the seizure. Stay with the child. Loosen clothing around the child's neck. RATIONALE: During a seizure, the child is placed on his or her side in a lateral position. The position will prevent aspiration because saliva will drain from the corner of the child's mouth. The child is not restrained because this could cause injury. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action could cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and observe and time the seizure.
The nurse prepares to care for a client who has undergone supratentorial cranial surgery. In which position should the nurse plan to place the client in the postoperative period? Flat Flat on the side that has been operated on With the head of the bed elevated 30 degrees On the back, with a small pillow under the head for support
With the head of the bed elevated 30 degrees RATIONALE: Supratentorial surgery is surgery above the brain's tentorium. After this type of surgery, the client is positioned with the head of the bed elevated 30 degrees or as tolerated to promote venous drainage from the head. Therefore, the remaining options are incorrect.
The nurse is monitoring a client who sustained a closed head injury in a motor vehicle accident for signs/symptoms of increased intracranial pressure (ICP). Which early sign/symptom does the nurse watch for? Confusion Slowed pulse rate Widened pulse pressure Increased systolic blood pressure
confusion RATIONALE: The earliest and most sensitive sign/symptom of increased ICP is a change in the client's LOC. Other early signs/symptoms include headache and pupil changes. The Cushing triad—increased systolic blood pressure with widening pulse pressure and bradycardia—is a late sign/symptom of increased ICP.
