Neuro

A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further skin care instructions are required if the client makes which statement?

"I need to scrub the skin vigorously with soap and water."

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the initial

check the toes

The nurse is told in report that a client has a positive Chvostek's sign. Which other data should the nurse expect to find on data collection? Select all that apply.

diarrehea, possible seizures, tetany, and positive for Trouss. sign

The nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. This conclusion is based on which findings? Select all that apply

drainage in the ear, bruising around the eye, pink-tinged color from nose

A client has just had skeletal traction applied following insertion of pins. The nurse should place highest priority

ensuring wts are hanging free

A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching

high calcium diet

The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement?

i can't swallow

The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives a test dose of edrophonium (Enlon). The nurse recalls that the client should have which reaction if the client has this disease?

increase in 1-3

The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action?

moves the cane when the right leg is moved

crainyectomy -runny nose

notify nurse

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which action should the nurse take next

notify regestered nurse

The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position?

8 inches to the front and side of the client's toes

A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate?

A window will be cut in the cast.

A client has had surgery to repair a fractured left hip. The nurse plans to use which important item when repositioning the client from side to side in the bed?

Abductor splint

The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint?

Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting.

A client with Bell's palsy exhibits facial asymmetry and cannot close the eye completely on one side. The client is also drooling and has loss of tearing in one eye. The nurse documents that the client displays symptoms of involvement of which cranial nerves (CNs)?

CN V11

A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study (studies) to determine the cause of the complaints? Select all that apply.

Cerebral angiography, Lumbar puncture (LP), Computed tomography

A client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. Which suggestion should the nurse include in the client's plan of care to alleviate this problem?

Consciously think about walking over imaginary lines on the floor.

The nurse is caring for the client with a head injury secondary to a motor vehicle crash. The nurse observes the client's status regularly, monitoring closely for which change in vital signs that could indicate increased intracranial pressure?

Decreasing pulse, decreasing respirations, increasing BP

A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before that. The findings have been reported to the health care provider, and the nurse anticipates a prescription for which medication?

Desmopressin (DDAVP)

The nurse is caring for a client with a diagnosis of osteoarthritis. Which would be least helpful for the client?

Increasingly vigorous and high-impact exercise

A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site?

Moist, sterile saline dressings

The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which outcome is noted?

bowel movements every 5 days

The clinic nurse is reviewing the medical record of a client scheduled to be seen in the clinic. The nurse notes that the client is prescribed selegiline hydrochloride (Eldepryl). The nurse understands that this medication is prescribed for which diagnosis?

Parkinson's disease

A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention?

Petaling the cast edges with adhesive tape

The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client?

Pillow to keep the right leg abducted during turning

A client who suffered a cervical spine injury had Crutchfield tongs applied in the emergency department. The nurse should avoid which action in the care of the client?

Removing the weights when repositioning the client

The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply.

bowel sounds, client ab distended, resp. excursion, accessory muscle

The nurse is caring for a client with osteoarthritis. The nurse monitors the client, knowing that which is a sign/symptom associated with the disorder?

pain is increased

residual diet

peas

The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client?

put in on left side to reach

A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse should monitor for which high-risk area for pressure and breakdown?

right heel

An older client with advanced Alzheimer's disease is placed in balanced suspension traction, and the health care provider expects to internally fixate the client's femur in 1 week. Based on this information, the nurse determines that the priority relates to addressing which client problem?

risk for constipation

Which symptoms would validate the diagnosis of a cluster headache? Select all that apply

runny nose, burning around the eye and tearing on the affected side

A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which position will be used during the procedure?

side lying with legs pulled up and the head bent

The nurse is reinforcing instructions to the client with a below-the-knee amputation (BKA) with regard to measures to protect the residual limb. The nurse should be sure to include which point in discussions with the client?

use mirror

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. Which documented early s/s

vertigo